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A  TEXT-'QOO^ew  York. 


OF 


Operative  Dentistry. 


BY 


THOMAS  FILLEBROWN,  M.D.,  D.M.D., 

PROFESSOR     OF    OPEKATIVE     DENTISTRY    IN    THE     DENTAL    SCHOOL    OF    HARVARD     INIVERSITY 

MEMBER    OK     THE    AMERICAN     DENTAL    ASSOCIATION,    AMERICAN 

ACADEMY   OF   DENTAL   SCIENCE,    ETC. 


WRITTEN  BY  INVITATION 

OF   THE 

NATIONAL    ASSOCIATION    OF    DENTAL    FACULTIES. 


THREE  HUNDRED  AND  THIRTY  ILLUSTRATIONS. 


PHILADELPHIA: 

P.   BLAKISTON,  SON   &  CO. 

IOI2    WALNUT    STREET. 
1889. 


f4^ 


Copyright,  1889,  by  P.  Blakiston,  Son  &  Co. 


Press  of  Wm  F.  Fell  &.  Co., 

1220-24  Sansom  St., 

philadelphia. 


PREFACE. 


For  many  years  the  author  has  felt  that  there  was  need  of 
a  text-book  on  Operative  Dentistry,  that  should  be  confined 
more  especially  to  the  descriptions  of  the  manual  operations 
required  for  the  preservation  of  the  natural  teeth. 

This  volume  is  the  result  of  this  feelinf^,  quickened  by  the 
invitation  of  the  National  Association  of  Dental  Faculties  to 
undertake  the  work. 

With  what  success  it  is  accomplished,  the  future  will  deter- 
mine. The  author  hopes  that  it  may  at  least  serve  as  one  step 
toward  the  production  of  something  that  shall  serve  the  pur- 
pose fully.  The  effort  has  been  made  to  avoid  unnecessary 
detail  and  to  leave  out  all  that  could  be  dispensed  with,  con- 
sistently with  clearness. 

Hence  History  has  not  been  attempted,  and  only  enough  of 
definitions,  etiology  and  symptoms  of  diseases  given  to  make 
clear  the  description  of  the  operation  to  be  performed.  While 
intending  to  include  the  principles  involved  in  all  ways  of  per- 
forming each  operation,  repetitions  under  the  heads  of  different 
methods  have  been  avoided,  and  authors'  names  have  been 
generally  omitted  from  the  text. 

The  work  is  not  intended  as  a  substitute  for  larger  works, 
but  as  an  epitome  of  the  practical  application  of  the  principles 
discussed  at  length  in  more  extensive  volumes,  and  to  these 
the  student  is  referred  for  exhaustive  discussion. 

The  most  advanced  nomenclature  has  been  adopted  as  far 
as  professional  sentiment  would  sustain  the  author. 

Canine  has  been  left  for  dogs  and  cuspid  constantly  used. 
Tartar  has  been  discarded  as  unscientific,  and  calculus  sub- 
stituted.    Hyjiercementosis  seems  to  fully  express  the  con- 

iii 


/ 


IV  PREFACE. 

ditions  of  the  cementum  so  long  called  exostosis,  which  seems 
applicable  only  to  affections  of  true  bone. 

Phagedenic  pericementitis  has  been  adopted  as  the  scientific 
name  of  the  condition  known  as  Riggs'  disease ;  this  has  been 
pointed  out  as  the  one  condition  that  obtains  throughout  the 
progress  of  the  disease  and  seems  eminently  suitable  and 
correct. 

The  author  desired  to  substitute  lingual  for  palatal  as 
applied  to  the  upper  teeth,  but  so  many  expressed  dissent  that 
the  latter  term  is  sustained. 

There  has  been  so  much  change  in  respect  to  nomenclature, 
it  was  thought  best  to  insert  articles  on  anatomy  and  physi- 
ology, so  that  those  parts  of  the  subject  should  correspond  with 
the  nomenclature  used  in  the  subsequent  pages  of  this  book. 
Similar  reasons  apply  to  the  writing  of  several  other  portions 
of  the  work.  With  few  exceptions,  all  of  the  first  and  second 
parts  have  been  written  expressly  for  this  work.  The  third 
part  on  Crown  and  Bridge  work  is  necessarily  largely  a  com- 
pilation. The  introduction  of  this  work  is  too  recent,  and  the 
methods  of  construction  too  diversified,  to  make  possible  any 
definite  system  which  should  appear  unquestionably  better 
than  all  others. 

This  work  is  classed  as  Operative  Dentistry  as  it  is  all 
dependent  upon  the  natural  teeth  for  support,  and  may  all  be 
done  at  the  operating  chair,  and  almost  all  of  it  is  much  better 
done  with  the  patient  present. 

All  Operative  Dentistry  is  mechanical,  and  crown  work  is  no 
more  so  than  filling  a  cavity,  applying  a  medicine  or  injecting 
an  abscess.  It  was  the  opinion  of  a  large  majority  of  the 
Dental  Faculties  that  it  should  be  properly  considered  as 
belonging  to  Operative  Dentistry,  and  in  dental  societies  it 
has  been  by  common  consent  considered  as  such. 

The  limited  time  the  author  could  devote  to  writing  of  this 
work  would  have  been  found  entirely  inadequate  for  the  task, 
but  for  the  clerical  and  literary  assistance  rendered  by  his 
professional  friend  and  former  pupil,  Dana  W.  Fellows,  m.  d. 


PREFACE.  V 

The  portions  treating  of  the  Anatomy  and  Physiology  of 
the  teeth  and  contiguous  parts  and  deciduous  and  permanent 
dentition  were  written  entirely  by  him,  and  much  critical 
assistance  rendered  throughout  the  book. 

Prof  Frank  Abbott,  m.  d.,  also  gave  the  author  valuable  help 
b\'  making  careful  and  extended  notes  on  the  manuscript. 

Important  suggestions  were  made  also  by  Profs.  S.  H. 
Guilford,  a.m.,  d.d.s.;  E.  T.  Darby,  m.d.,  d.d.s.;  C.  N.  Pierce, 
D.D.S.;  A.  H.  Fuller,  .m.d.,  d.d.s.;  T.  E.  Weeks,  d.d.s.;  Edmund 
Noyes,  d.d.s.;  H.  W.  Morgan,  m.d.,  d.d.s.;  S.  W.  Dennis,  m.d., 
d.d.s.;  T.  H.  Chandler,  d.m.d.,  and  Wm.  H.  Atkinson,  m.d. 

Thanks  are  due  to  the  S.  S.  White  Dental  Manufacturing 
Co.  for  the  use  of  so  many  of  their  electrotypes  for  the  ex- 
cellent illustrations  appearing  in  these  pages,  also  to  the  pub- 
lishers of  the  "American  System  of  Dentistry,"  and  to 
Claudius  Ash  &  Sons,  of  London,  for  like  favors. 

THOMAS  FILLEBROWN. 

Boston,  December  iji/i,  1888. 


A 


CONTENTS. 


PACB 

The  Alveolar  Processes  and  Articulation  of  the  Teeth, 9 

Occlusion  of  the  Teeth 10 

The  Dental  Tissues, n 

Dentine,  11  ;   Enamel,  11  ;  Coinentum,  12  ;   Pericementum,  12. 

The  Deciduous  and  Termanent  Dentitions, 12 

Eruption  of  the  Teeth,  13;  Periods  of  Dentition,  13;  Classes  of  Teeth,  14;  Anatomi- 
cal Divisions  of  a  Tooth,  14  ;  Description  of  the  Permanent  Teeth,  15  ;  Teeth  of 
the  Lower  Jaw,  20;  The  Deciduous  Teeth,  23. 

Dental  Caries — Clinical  History,      24 

Working  Steel 27 

Making  Instruments  from  Piano  Wire,  29;  Drawing  Swiss  Broaches  to  a  Spring  Tem- 
per, 29;  Rendering  Swiss  Broaches  Soft,  29. 

Instruments, 3° 

Instruments  for  Pulp  Canals,  33  ;  Instruments  for  Cleaning  Teeth,  34  ;  Instruments 
for  Filling,  36;  Pluggers  for  Gold,  37;  Clamps,  38  ;  Burnishers,  42;  Finishing 
Instruments,  43;  The  Dental  Engine,  43. 

The  Dentist  Himself, 46 

Manner  of  Holding  Instruments, 47 

Examination  of  the  Mouth,      5° 

Deposits  on  the  Teeth 5^ 

Cleansing  Teeth 54 

Separating  Teeth, 5^ 

Opening  Cavities, 59 

Removal  of  Decayed  Dentine, .- 60 

Formation  of  Cavities  for  Filling, 60 

Exclusion  of  Moisture, 62 

Gold  for  Filling, 6S 

The  Adams  Roller,  69  ;  The  Mat,  70  ;  The  Block,  70  ;  The  Compact  Cylinder,  71  ; 
Rolled  Gold  73;   Cryst.-il  Gold,  75  ;    Annealing  Gold,  76. 

The  Dental  Matrix, 76 

Use  of  the  Mallet, 79 

Plastic  Fillings, 84 

Gutta  Percha, 86 

Cements, 87 

Combination  Fillings, 88 

Porcelain  Disk  Fillings, 89 

Erosion, 9° 

Sensitive  Dentine, 9' 

Secondary  Dentine, 9^ 

vii 


Vlll  CONTENTS. 

PAGE 

The  Dental  Pulp 94 

Sensitive  Pulp,  94  ;  Exposed  Pulp,  94;  Irritation,  95  ;  Congestion  and  Inflammation, 
95  ;  Devitalization  of  Pulp,  96;  Removal  of  Pulp,  97;  Extirpation  of  Pulp,  98  ; 
General  AnKsthesia  in  Removal  of  Pulp,  98  ; 

Preparation  of  Roots  for  Filling, 99 

Filling  Roots  of  Teeth 100 

Gold,  Gutta  Percha,  100;  Oxychloride  of  Zinc,  Oxyphosphate  of  Zinc,  loi. 

Bleaching  Discolored  Teeth, loi 

Treatment  of  First  Molars, 102 

Tliird  Molars,  104. 

Treatment  of  the  Temporary  Teeth, 104 

Hypercementosis, 106 

Pericementitis, 106 

Necrosis  of  Teeth, no 

Replantation  of  Teeth, no 

Alveolar  Abscess, in 

Extracting  Teeth, 116 

Syncope,  119;   Hemorrhage,  119. 

Instruments  for  Extracting  Teeth,   . 121 

Position  of  Patient  and  Operator, 132 

Extracting  Roots, 135 

Elevator,  139  ;  The  Key,  139. 
Anaesthesia, 142 

Nitrous  Oxide,  143  ;  Ether,  145  ;  Conditions  unfavorable   to  Anaesthesia,  146  ;  Chlo- 
roform, 146 ;  Rapid  Breathing,  147  ;  Local  Anassthesia,  147  ;    Unfavorable  Symp- 
toms, 147. 
Crown  Work, 149 

Preparing  the  Roots,  154;  Richmond  Crown,  155;  Gold  Cap  Crowns,  158. 

The  Mandrel  System, 166 

Crown  with   Metal   Post,  without  Band,  176 ;  the  Logan  Crown,   177;  the  Parmly  Brown 

Crown,   181 ;  the  Collar  Crown,  182  ;  the  Bonwill   Crown,  190;  the    How  Crown,  193  : 

Baldwin's  Crown,  199  ;  Low's  Crown,  201 ;  the  Improved  Richmond   Crowns,  206 ; 

Meriam  Crowns,  207;  the  Mattison  Crown,  211;  Dr.  Kirk's  Crown,  214;  the  Leech 

Crown,  216  ;  the  Stowell  Crown,  217. 
Bridge  Work, 221 

Low  Bridge,  241  ;   Parmly  Brown  Bridge,  250 ;  Cryer's  Bridge,  253  ;   Melotte's  Bridge, 
254;  Richmond  Removable  Bridge,  258  ;  Starr's  Removab'e  Bridge,  258. 

Repairing  Crown  and  Bridge  Work, 262 

Appendix,       265 

Formulas  for  Alloys,  265  ;   Medicaments  used  in  Operative  Dentistry,  267. 

Index, 271 


OPERATIVE  DENTISTRY. 


THE  ALVEOLAR  PROCESSES  AND  ARTICULATION  OF  THE 

TEETH. 

For  a  description  of  the  bone.s  of  the  face  the  student  is 
referred  to  works  on  anatomy. 

By  the  form  of  articulation  known  as  gomphosis,  the  teeth 
are  implanted  in  the  alveolar  processes,  portions  of  the  max- 
illary bones,  which  in  regard  to  their  development,  form  and 
duration  are  entirely  subservient  to  the  teeth.  These  portions 
of  the  maxillary  bones,  with  which  the  teeth  have  so  intimate 
a  connection,  and  which  have  so  many  important  relations  to 
operative  dentistry,  should  receive  special  attention.  These 
are  best  described  as  consisting  of  two  plates  of  bone,  an 
outer  and  an  inner  plate,  the  alveoli  being  formed  by  septa 
passing  across  between  the  plates. 

The  outer  plate,  continuous  with  the  facial  surface  of  the 
maxillary  bone  in  the  upper  jaw,  is  very  thin,  and  marked  by 
eminences  corresponding  to  the  alveoli  which  contain  the 
roots  of  the  teeth,  that  over  the  cuspid  being  specially  promi- 
nent, and  known  as  the  canine  eminence,  behind  which  is  the 
canine  fossa,  and  in  front  the  incisive  or  myrtiform  fossa. 

The  inner  plate  is  much  thicker  and  stronger  and  merges 
into  the  palate  processes.  After  extraction  of  the  teeth  of  the 
upper  jaw,  the  thin  external  alveolar  plate  is  absorbed  more 
quickly  and  to  a  greater  extent  than  the  inner. 

In  the  lower  jaw  the  external  plate  is  thick  and  strong, 
except  in  front,  and  after  extraction  of  the  teeth  the  absorption 
of  the  two  plates  is  nearly  uniform. 

The  socket  for  each  tooth  conforms  exactly  to  the  root  or 

9 


lO  OPERATIVE    DENTISTRY. 

roots  which  it  contains,  and  consists  of  a  thin  shell  of  dense 
bone,  which  is  surrounded  by  spongy  tissue,  and  is  continuous 
at  the  free  margin  with  the  dense  cortical  bone  of  the  jaw. 
The  walls  are  perforated  by  numerous  foramina,  and  at  the 
bottom  of  each  alveolus  or  each  division  is  a  larger  foramen 
for  the  transmission  of  vessels  and  nerves  to  the  dental  pulp 
and  pericementum.  The  bony  septa  between  the  alveoli  rise 
tD  a  higher  level  on  the  teeth  in  both  jaws  than  the  outer  and 
inner  walls.  This  should  not  be  forgotten  in  the  fitting  of 
bands  and  crowns  to  the  roots  of  teeth. 

OCCLUSION  OF  THE  TEETH. 

In  the  normal  human  denture  the  teeth  are  arranged  in  a 
parabolic  curve;  every  tooth  touches  those  at  each  side,  and 
the  cusps  and  cutting  edges  of  all  are  on  nearly  the  same  level. 
The  plane  of  the  grinding  surfaces  of  the  molars  rises  a  little, 
however,  from  the  first  to  the  third,  so  that,  viewed  from  the 
side,  a  gentle  curve  is  seen,  with  the  concavity  directed  upward. 

The  arch  of  the  upper  denture  is  a  somewhat  larger  curve 
than  that  of  the  lower,  and  in  normal  occlusion  the  upper  front 
teeth  shut  over  and  in  front  of  those  of  the  lower  jaw.  The 
bicuspids  and  molars  of  the  upper  jaw  also  project  beyond  the 
corresponding  lower  teeth,  so  that  the  buccal  cusps  of  the 
latter,  in  the  closure  of  the  mouth,  come  between  the  buccal 
and  lingual  cusps  of  those  above. 

It  will  be  seen,  also,  that  no  tooth  in  either  denture  is  exactly 
opposed  to  any  one  in  the  other,  but  that  in  normal  occlusion 
each  tooth  comes  in  contact  with  two  in  the  opposite  jaw, 
except  the  upper  third  molar,  which,  being  smaller  than  the 
lower  third  molar,  occludes  with  the  posterior  two-thirds  of 
this  tooth,  and  the  inferior  central  incisor,  which  is  opposed  to 
the  superior  central  incisor  only. 

By  the  arrangement  thus  briefly  described  the  cusps  of 
the  bicuspids  and  molars  of  either  jaw  shut  into  the  depres- 
sions between  the  cusps  of  the  teeth  in  the  opposite  jaw,  thus 
securing  a  firmer  occlusion  and  greater  efficiency  in  mastica- 


THE    DENTAL   TISSUES.  II 

tion  than  could  otherwise  be  obtained.  Moreover,  if  any  one 
tooth  be  lost,  those  in  the  opposite  jaw  will  still  retain  a  par- 
tial occlusion  with  the  contiguous  teeth. 

THE  DENTAL  TISSUES. 

Three  kinds  of  calcified  tissue — dentine,  enamel  and  cemen- 
tum — enter  into  the  structure  of  a  human  tooth,  and  these, 
though  not  absolutely  peculiar  to  the  teeth,  are  appropriately 
called  dental  tissues. 

Dentine  incloses  the  pulp  chamber  and  makes  up  the  greater 
part  of  the  tooth.  That  portion  above  the  neck  is  invested 
with  a  layer  of  enamel  of  varying  thickness,  and  is  described 
as  the  crown  of  the  tooth,  while  a  layer  of  cementum  covers 
the  root  and  usually  overlaps  the  enamel  to  a  slight  extent. 
If  the  two  last-named  tissues  be  entirely  removed,  the  dentine 
will  still  show  the  general  form  of  the  tooth,  reduced  in  size 
and  with  the  extremities  of  the  roots  and  cusps  quite  thin  and 
pointed. 

As  to  its  physical  properties,  dentine  is  hard,  dense  and  highly 
elastic,  yellowish-white  in  color  and  somewhat  translucent,  frac- 
tured surfaces  showing  a  silky  lustre. 

Chemical  analysis  of  perfectly  dry  dentine  shows  it  to  con- 
sist of  about  28  per  cent,  animal  and  72  per  cent,  mineral 
matter,  the  latter  being  mostly  phosphate  of  lime.  About  10 
per  cent,  of  the  fresh  tooth  is  water.  The  constituents  vary, 
not  only  in  different  individuals,  but  probably  in  the  same 
individual  at  different  ages  and  under  different  conditions. 

The  structural  elements  of  dentine  are  the  matrix,  richly 
impregnated  with  calcareous  salts,  the  dentinal  tubes,  and  the 
soft  fibrils.  Each  tube  passes,  with  some  variation  in  direction 
and  curvature,  from  its  opening  on  the  wall  of  the  pulp  cavity 
toward  the  surface  of  the  dentine.  These  tubes  contain  the 
soft  fibrils,  which  are  prolongations  of  the  cells  at  or  near  the 
surface  of  the  pulp. 

Enamel. — Well-formed  enamel  is  by  far  the  hardest  of  all 
animal  tissues,  containing  also  the  smallest  proportion  of  or- 


12  OPERATIVE    DENTISTRY. 

ganic  constituents — from  3>^  to  5  per  cent.  Nearly  90  per 
cent,  is  phosphate  of  lime. 

Human  enamel  is  translucent,  pearly-white  in  color,  with 
often  a  tinge  of  yellow. 

In  structure  it  consists  of  enamel  fibers  or  prisms,  hexagonal 
in  shape  and  in  very  close  apposition,  if  not  in  actual  contact. 
The  course  of  these  is,  in  a  general  way,  from  the  dentine 
outward,  at  right  angles  with  its  surface.  Enamel  has  a  defi- 
nite cleavage,  the  line  of  fracture  passing  not  between  the 
prisms,  but  through  their  centres. 

Cementum. — This  tissue  is  in  all  respects  very  much  hke 
true  bone.  It  differs  from  bone  in  having  lacunae  more  vari- 
able in  size  and  form,  and  canaliculi  in  greater  number  and  of 
greater  length.  When  the  cementum  is  very  thin,  as  at  the 
neck  of  a  tooth,  it  is  apparently  structureless. 

Pericementum. — This  membrane  covers  the  root  of  the 
tooth,  lying  between  it  and  the  bony  socket.  It  serves  as  a 
means  of  attachment  and  a  medium  of  nutrition  to  the  ce- 
mentum, and  also  acts  as  a  cushion  to  lessen  the  shock  of 
occlusion.  It  consists  of  fibrous  connective  tissue,  and  is 
richly  supplied  with  vessels  and  nerves.  It  is  thicker  near 
the  neck  of  the  tooth,  where  it  is  continuous  with  the  gum 
and  periosteum  of  the  alveolar  process.  It  is  also  thicker 
nearer  the  apex  of  the  root.  The  direction  of  the  fibers  is 
obliquely  across  from  the  alveolar  wall  to  the  cementum,  and, 
although  the  membrane  varies  histologically  in  different  parts 
of  its  thickness,  it  is  probably  but  a  single  membrane. 

THE  DECIDUOUS  AND  PERMANENT   DENTITIONS. 

Man,  in  common  with  most  mammals,  is  provided  with  two 
sets  of  teeth,  known  as  the  deciduous  and  the  permanent  set. 

The  deciduous  teeth,  which  are  adapted  to  the  requirements 
of  childhood,  are  fewer  in  number  and,  as  regards  teeth  of  the 
same  class,  smaller  than  their  successors.  They  constitute  the 
dental  apparatus  of  the  child  from  the  time  of  their  eruption 
to  the  age  of  six  years,  when  the  first  permanent  molars  ap- 


THE    DECIDUOUS    AND    PERMANENT    DENTITIONS.  1 3 

pear.  The  teeth  last  named  are  thus  accessory,  as  regards 
function,  to  the  deciduous  dentition,  though  anatomically  they 
are  quite  distinct,  and  have  relations  entirely  with  the  perma- 
nent set. 

Formula  of  the  deciduous  dentition — 

d  i  I,  d  c  |,  d  m  §  =  }g  =  20. 

The  ten  anterior  permanent  teeth  in  each  jaw  replace  the 
deciduous  teeth,  while  the  twelve  molars  appear  posterior  to 
these  and  have  no  predecessors. 

Formula  of  the  permanent  dentition — 

i  |,  c  ^,  p  m  |,  m  f  =  -}«.  =  32. 

In  both  deciduous  and  permanent  dentitions  the  teeth  are 
symmetrical  on  the  two  sides  of  each  jaw,  and  equal  in  number 
though  not  symmetrical  in  the  two  jaws. 

Eruption  of  the  Teeth. — The  time  of  eruption  of  the 
deciduous  and  permanent  teeth  is  subject  to  great  variation, 
hence  tables  prepared  by  different  observers  do  not  agree.  It 
is  believed  that  the  following  tables  are  correct  for  the  usual 
or  average  age  at  which  the  several  classes  of  teeth  appear : — 

DECIDUOUS.  PERMANENT. 

Incisors,  inferior  and  First  molars,      ....  6  years. 

superior,     ....    5  to   8  months.     Incisors, 7  to    8      " 

First  molars    .    .    .    .  14  to  16      "  Bicuspids, 9  to  10      " 

Cuspids, 17  to  20      "  Cuspids, II      " 

Second  molars,  .    .    .  20  to  30      *'  Second  molars,    ...  12      " 

Third  molars,    ....  16  to  25      " 

The  lower  teeth  in  each  dentition  appear  a  little  earlier  than 
the  upper. 

Periods  of  Dentition. — A  comparison  of  the  above  tables 
will  show  that  the  first  dentition  is  completed  at  the  age  of  two 
and  a  half  years.  These  twenty  teeth  exercise  their  functions 
during  the  three  or  four  years  that  follow  ;  at  six  years  of  age 
the  first  permanent  molars  appear,  and  the  child  then  has 
twenty-four  teeth  ;  during  the  six  years  between  this  period 
and  the  age  of  twelve  the  deciduous  teeth  are  all  replaced  by 
their  permanent  successors,  and  the  second  permanent  molars 


14  OPERATIVE    DENTISTRY. 

are  erupted,  so  that  during  the  next  six  years  the  mouth  con- 
tains twenty-eight  teeth ;  finally,  at  eighteen,  often  not  until 
much  later,  the  second  dentition  is  completed  by  the  eruption 
of  the  third  molars. 

Classes  of  Teeth. — The  teeth  in  each  set  are  classified  and 
named  with  reference  to  their  form  and  relative  position  in  the 
mouth.  Thus,  the  permanent  teeth  are  divided,  with  reference 
to  their  form,  into  four  classes,  namely,  incisors,  cuspids,  bi- 
cuspids and  molars.  Those  in  the  upper  jaw  are  described  as 
the  superior  or  upper  teeth,  and  those  in  the  lower  jaw  as  the 
inferior  or  lower  teeth.  They  are  further  designated  as  right 
or  left,  according  to  the  position  they  occupy  with  respect  to 
the  median  plane  of  the  body.  In  each  of  these  divisions, 
namely,  superior  right  and  left  and  inferior  right  and  left,  are 
two  incisors,  one  cuspid,  two  bicuspids  and  three  molars. 
The  incisors  are  usually  distinguished  as  central  and  lateral, 
but  first  and  second  incisor  is  better,  as  with  the  bicuspids 
which  are  known  as  the  first  and  second,  and  the  molars  as 
the  first,  second,  and  third,  the  first  being  in  all  cases  the 
anterior  tooth  of  the  class,  or,  in  other  words,  the  one  nearest 
the  median  plane  following  the  line  of  the  dental  arch. 

Anatomical  Divisions  of  a  Tooth. — For  description  each 
tooth  is  divided  into  crown,  neck  and  root. 

The  crown  is  that  part  which  is  covered  with  enamel,  and 
which  in  a  normal  tooth  fully  erupted  is  seen  above  the  gum. 

The  neck  is  a  slight  constriction  immediately  below  the 
margin  of  the  enamel  which  is  closely  embraced  by  the  free 
margin  of  the  gum.  This  anatomical  division  of  the  tooth 
merits  careful  study  on  account  of  the  important  relations  it 
bears  to  the  operation  of  extraction  and  to  the  fitting  of 
bands  and  porcelain  crowns. 

The  root  is  implanted  in  the  bony  socket  and  includes  all 
below  *  the  neck. 

*  The  terms  above,  below,  etc.,  have  reference  to  the  crown  and  root  extremi- 
ties of  the  tooth ;  thus,  the  term  above,  signifies  toward  the  cutting  or  grinding 
surface  of  a  tooth,  and  below,  toward  the  apex  of  the  root. 


THE    DECIDUOUS    AND    PERMANENT    DENTITIONS.  1 5 

Surfaces  of  Teeth. — The  surfaces  of  teeth  are  named  from 
their  relations  in  the  mouth  to  each  other  and  to  other  parts. 

Labial  and  buccal  surfaces  are  those  which  present  toward 
the  Hps  and  cheeks,  the  term  labial  being  applied  to  incisors 
and  cuspids,  and  buccal  to  bicuspids  and  molars  in  either  jaw. 

Litigual  surfaces  are  those  on  all  the  teeth  in  both  jaws 
presenting  toward  the  tongue  or  the  cavity  of  the  mouth. 
This  surface  on  the  upper  teeth  is  more  commonly  called 
palatal. 

The  labial  and  buccal  surfaces  are  sometimes  called  cxtcr- 
fial  and  the  lingual  internal. 

Proximal  surfaces  are  those  which  are  next  to  each  other  in 
adjoining  teeth  of  the  same  jaw. 

Mesial  surfaces  are  those  proximal  surfaces  which  present 
toward  the  median  line  of  the  dental  arch. 

Distal  surfaces  are  those  on  the  opposite  side  of  the  tooth 
to  the  mesial,  or  presenting  from  the  median  line  of  the  arch. 

As  applied  to  bicuspids  and  molars,  anterior  is  synonymous 
with  mesial  and  posterior  with  distal. 

Cutting  edges  pertain  to  incisors  and  cuspids  and  grinding 
or  occluding  surfaces  to  bicuspids  and  molars. 

For  more  accurate  description,  combinations  of  the  terms 
given  above  are  used.  Their  form  will  explain  their  significa- 
tion, as  labio-mesial  angle,  the  angle  formed  by  the  union  of 
the  labial  and  mesial  surfaces.  These  terms  are  properly 
employed  with  reference  to  the  roots  as  well  as  to  the  crowns 
of  teeth. 

Description  of  the  Permanent  Teeth. — Superior  Central 
Incisor  (Fig.  i,  a,  p.  22). — The  crown  of  this  tooth  is  chisel- 
shaped.  The  cutting  edge,  which  is  the  broadest  part,  is  nearly 
straight  across,  but  is  a  little  more  rounded  at  the  distal  angle 
than  at  the  mesial.  In  recently-erupted  incisors  the  cutting 
edge  is  divided  into  three  nearly  equal  parts  by  two  slight 
notches,  which  soon  disappear  by  wear  when  the  tooth  comes 
into  use.  The  middle  point  of  the  cutting  edge  is  on  a  line 
with  the  lone  axis  of  the  tooth. 


l6  OPERATIVE    DENTISTRY. 

The  labial  surface  is  somewhat  quadrangular  in  outline, 
convex  in  all  directions  and  usually  quite  smooth,  though 
sometimes  two  shallow  grooves  run  from  the  cutting  edge  to 
the  cervical  border.  The  cervical  border  is  formed  by  the 
curved  edge  of  the  enamel  at  the  margin  of  the  gum,  the  con- 
cavity of  the  curve  looking  toward  the  crown  of  the  tooth. 

The  palatal  surface  is  concave  and  often  somewhat  grooved 
longitudinally.  The  cervical  border  is  formed  by  the  cingule, 
a  more  or  less  prominent  ridge  of  enamel  which  is  continuous 
at  each  side  with  the  proximo-palatal  borders,  and  near  the 
cingule  on  the  palatal  surface  there  is  frequently  a  pit  or  other 
imperfection  in  the  enamel. 

The  proximal  surfaces  are  triangular,  having  the  base  of  the 
triangle  at  the  cervical  border  and  the  apex  at  the  cutting  edge. 
The  enamel  border  on  these  surfaces  is  somewhat  V-shaped 
with  a  rounded  angle,  the  latter  being  directed  toward  the  cut- 
ting edge  of  the  tooth.  The  distal  surface  is  a  little  more 
convex  than  the  mesial,  and  a  little  shorter. 

The  neck  of  a  central  incisor  is  nearly  cylindrical,  with  a 
tendency  toward  a  triangular  form,  broader  toward  the  labial 
side,  and  the  root  nearly  conical  and  usually  quite  straight. 

Superior  Lateral  Incisor  (Fig.  i,  b,  p.  22). — The  crown  is 
similar  in  form  to  that  of  the  central,  but  it  is  in  every  respect 
smaller.  The  form  of  the  cutting  edge  is  less  constant,  but  the 
angle  at  the  mesial  side  is  usually  acute,  and  the  distal  side 
much  rounded  off.  This  gives  to  the  labial  surface  an  irregular 
outline,  with  the  mesial  border  longer  than  the  distal ;  this  sur- 
face is  slightly  convex  in  all  directions,  with  the  cervical  border 
curved  like  that  of  the  central. 

The  palatal  surface  is  a  little  flatter  than  that  of  the  central, 
but  the  cingule  is  usually  more  pronounced,  and  the  pit  near 
it  is  more  constant  and  deeper. 

The  proximal  surfaces  correspond  in  general  form  to  the 
same  surfaces  of  the  central,  but  the  mesial  surface  is  less 
convex  and  the  distal  rather  more  so. 

The  neck  is  much  flattened  mesio-distally,  and  the.  same  form 


THE    DECIDUOUS    AND    PERMANENT    DENTITIONS.  J 7 

is  retained  throughout  the  whole  extent  of  the  root,  which  is 
often  bent  near  the  apex  toward  the  distal  side.  The  root  is 
slender  and  longer  in  proportion  to  its  siz.e  than  that  of  the 
central. 

To  determine  to  which  side  a  superior  incisor,  either  central 
or  lateral  belongs,  let  the  student  hold  the  tooth  with  the  crown 
downward,  and  looking  at  the  labial  surface,  if  the  longer  border 
and  more  acute  angle  of  the  cutting  edge  be  toward  his  right, 
it  is  a  right  tooth,  if  toward  his  left,  it  is  a  left  tooth. 

Superior  Cuspid  (Fig.  i,  c,  p.  22). — The  superior  cuspid  is 
the  longest  tooth  in  the  entire  series.  The  crown  is  thick  and 
strong,  having  a  single  rounded  cusp  in  a  line  with  the  long 
axis  of  the  tooth.  The  slope  from  this  to  the  mesial  surface 
is  shorter  than  on  the  distal  side. 

The  labial  surface  is  convex,  especially  from  side  to  side, 
with  a  rounded,  longitudinal  ridge  running  its  entire  length, 
and  on  each  side  of  this  a  slight  depression. 

The  palatal  surface  has  a  similar  ridge  with  a  depression  at 
each  side,  or  it  is  irregularly  convex,  with  the  cingulc  thick 
and  often  prominent. 

The  distal  surface  is  a  little  more  prominent  and  a  little  more 
rounded  than  the  mesial.  The  form  of  the  neck  in  section  is 
triangular,  with  angles  much  rounded,  the  root  becoming 
somewhat  more  flattened,  with  a  groove  at  each  side.  The  root 
is  also  thick  and  considerably  longer  than  the  roots  of  the 
incisors. 

Hold  the  tooth  as  directed  for  an  incisor,  and  the  shorter 
slope  from  the  point  of  the  cusp  to  the  proximal  surface  will 
indicate  the  side  to  which  the  tooth  belongs,  the  shorter  side 
being  the  mesial. 

Superior  Bicuspids  (Fig.  i ,  d,  e,  p.  22). — By  some  writers  these 
are  called  premolars. 

The  grinding  surface  supports  two  cusps  of  nearly  equal 
length,  that  on  the  palatal  side  being  regarded  as  the  cingule 
before  mentioned  developed  into  the  prominence  of  a  cusp. 
The  buccal  cusp  is  thicker  and  stouter.     This  surface  presents 


16  OPERATIVE    DENTISTRY. 

an  outline  somewhat  quadrilateral  in  form ;  the  palatal  border, 
however,  is  much  rounded,  while  the  buccal  portion  is  broader 
and  the  angles  distinct,  giving  to  the  tooth,  at  the  base  of  this 
cusp,  its  greatest  diameter  from  the  mesial  to  the  distal  surface. 
The  two  cusps  are  separated  by  a  distinct  fissure  which  is 
nearly  straight,  and  is  limited  at  each  end  by  ridges  of  enamel 
at  the  mesial  and  distal  borders,  the  mesial  border  being  higher 
than  the  distal  in  all  the  bicuspids. 

The  buccal  surface  is  strongly  convex  in  all  directions  and 
similar  in  outline  to  the  corresponding  surface  of  the  cuspid. 

The  palatal  surface  much  resembles  the  buccal,  but  it  is  not 
as  broad  and  is  more  rounded  from  side  to  side. 

The  proximal  surfaces  slope  toward  each  other  from  the 
grinding  surface,  so  that  at  the  neck  these  surfaces  are  nearly 
or  quite  flat,  or  even  concave. 

A  cross  section  at  the  neck  shows  an  elongated  outline,  often 
a  little  constricted  at  the  middle  by  the  beginning  of  the 
grooves  which  pass  down  the  mesial  and  distal  surfaces  of  the 
single  flattened  roots.  More  frequently,  however,  the  first 
superior  bicuspid  has  the  root  divided  into  two  for  one-third  of 
its  length.  Sometimes  the  root  of  the  second,  also,  is  divided 
to  some  extent.  The  crown  of  the  second  bicuspid  is  usually 
a  little  larger  than  that  of  the  first,  the  palatal  cusp  being  more 
fully  developed  and  often  as  long  as  the  buccal. 

To  determine  to  which  side  a  bicuspid  belongs,  hold  the  tooth 
horizontally  with  the  buccal  surface,  which  may  be  known  by 
its  greater  breadth,  upward,  and  looking  at  the  grinding  sur- 
face, the  higher  proximo-grinding  ridge  and  the  closer  prox- 
imity of  the  cusps,  especially  the  lingual  cusp,  will  indicate  the 
side  to  which  it  belongs. 

Superior  Molars  (Fig.  i,  f,  g.  p.  22). — These  have  large, 
square-shaped  crowns  specially  adapted  for  crushing  and  grind- 
ing. The  following  description  will  apply  to  the  first  and  second 
molars,  but  while  the  first  is  quite  constant  in  form,  the  second 
is  more  variable. 

The  grinding  surface  has  a  rhombic  outline  with  rounded 


THE    DECIDUOUS    AND    PERMANENT    DENTITIONS.  I9 

angles.  The  niesio-buccal  and  disto-palatal  angles  are  acute 
and  the  meslo-palatal  and  disto-buccal  obtuse.  On  the  surface 
are  four  cusps,  one  at  each  angle,  the  mesio-palatal  being  con- 
siderably the  largest,  the  mesio-buccal  next  in  size  and  the 
linguo-distal  the  smallest.  The  linguo-mesial  cusp  is  con- 
nected with  the  disto-buccal  by  a  thick,  oblique  ridge,  and 
between  this  ridge  and  the  mesio-buccal  cusp  is  a  deep  depres- 
sion, from  which  a  fissure  extends  toward  and  often  through 
the  buccal  border.  Another  extends  toward  the  mesial  bor- 
der and  a  third  runs  into  the  oblique  ridge.  Between  the  mid- 
dle portion  of  the  oblique  ridge  and  the  linguo-distal  cusp  is 
another  deep  depression,  with  a  fissure  extending  frequently 
through  the  lingual  border,  while  the  other  extremity  of  the 
fissure  rarely  extends  far  enough  to  divide  the  distal  border. 
The  linguo-distal  cusp  thus  separated  is  to  be  regarded  as  the 
cingule,  the  other  three  being  true  cusps. 

The  buccal  surface  is  divided  nearly  in  the  middle  by  a  per- 
pendicular groove  which  is  continuous  with  that  on  the  grind- 
ing surface.  The  mesial  portion  of  this  surface  is  much  more 
prominent  than  the  distal,  which  slopes  backward.  The  lin- 
gual surface  is  similarly  divided,  the  distal  portion  being  the 
more  prominent. 

The  proximal  surfaces  are  broad  and  convex,  becoming  flat 
at  the  cervical  portion. 

A  section  at  the  neck  shows  an  outline  similar  to  that  of  the 
grinding  surface,  four-sided  with  unequal  angles. 

The  root  is  divided  into  three,  one  large  and  nearly  conical, 
diverging  inward,  and  called  the  palatal  root,  and  two  buccal, 
the  mesio-buccal  much  larger  than  the  distal,  and  both  much 
flattened  mesio-distally. 

Frequently  the  disto-buccal  and  palatal  roots  are  united 
throughout  their  whole  extent. 

The  superior  third  molar  sometimes  conforms  to  the  descrip- 
tion above  given,  but  usually  the  crown  is  smaller  and  of  very 
irregular  form,  and  the  roots  united  into  one  throughout  the 
whole  or  greater  part  of  their  extent. 


20  OPERATIVE    DENTISTRY, 

If  the  student  hold  an  upper  molar  with  the  crown  down- 
ward and  the  two  buccal  roots  next  to  himself,  the  larger  and 
broader  root  will  be  toward  the  side  to  which  the  tooth 
belongs. 

Teeth  of  the  Lower  Jaw. — The  inferior  central  incisor 
(Fig.  I,  I,  p.  22)  is  the  smallest  tooth  in  either  denture. 

The  lateral  incisor  (Fig.  i,  j,  p.  22)  is  a  little  wider  and  the 
root  considerably  longer.  The  width  of  these  two  teeth  is 
about  three-fourths  as  great  as  that  of  the  two  corresponding 
superior  incisors. 

The  cutting  edge  of  an  inferior  incisor  is  straight  and  nearly 
at  right  angles  to  the  long  axis  of  the  tooth,  though  the  distal 
angle  is  usually  a  little  lower  than  the  mesial. 

The  labial  surface  is  widest  at  the  cutting  edge  and  narrow- 
est at  the  neck,  the  proximal  borders  converging  equally  from 
the  cutting  edge  downward.  The  enamel  border  at  the  neck 
is  not  prominent,  and  the  surface  is  but  slightly  convex  from 
above  downward. 

The  lingual  surface  is  flat  from  side  to  side  at  its  upper 
part,  and  rounded  below  and  slightly  concave  from  above 
downward.     The  cingule  is  not  developed. 

The  proximal  surfaces  are  nearly  equal,  flat  and  triangular, 
with  the  cervical  border  of  enamel  quite  thin. 

A  cross-section  at  the  neck  is  elliptical  and  quite  narrow 
mesio-distally,  and  the  root  much  flattened  in  the  same  direc- 
tion. 

Tlie  Lower  Cuspid  {Y\^.  i,  k,  p.  22). — This  tooth,  compared 
with  the  upper  cuspid,  is  smaller  and  less  specialized  in 
form,  resembling  somewhat  the  conical  teeth  of  the  lower 
orders  of  animals.  The  crown  is  narrower  and  more  elongated 
than  that  of  the  upper  tooth. 

The  labial  surface  is  rounded  and  rather  more  prominent 
near  the  mesial  border  than  elsewhere,  and  quite  strongly  con- 
vex from  above  downward. 

The  lingual  surface  is  flat  or  slightly  concave,  and  the 
proximal  surfaces  triangular,  the  mesial  somewhat  the  larger. 


THE    DECIDUOUS    AND    PERMANENT    DENTITIONS.  21 

A  transverse  section  of  the  neck  is  oval  in  form,  witli  the 
labial  portion  wider. 

Inferior  Bicuspids  (Fig.  i,  i.,  m,  p.  22). — The  first  bicuspid  is 
smaller  than  the  second,  the  buccal  cusp  is  prominent  and  the 
lingual  small  and  often  very  short.  The  two  cusps  are  united 
by  a  stout  ridge  of  enamel  passing  across  with  a  pit  at  each 
side. 

The  buccal  surface  is  prominent  below  and  slopes  rapidly 
away  toward  the  grinding  surface.  From  side  to  side  it  is 
moderately  convex. 

The  lingual  surface  is  more  prominent  at  its  upper  portion, 
making  the  tooth  appear  bent  inward  at  the  neck. 

The  proximal  surfaces  are  smoothly  convex  from  side  to 
side  and  most  prominent  near  the  upper  border. 

A  transverse  section  at  the  neck  is  nearly  circular,  the  root 
nearly  round  and  often  but  slightly  tapering. 

The  inferior  second  bicuspid  corresponds  to  the  description 
just  given,  except  that  the  crown  is  larger  and  the  lingual 
cusp  more  fully  dev^eloped,  with  a  tendency  to  the  formation 
of  two  lingual  cusps.  A  like  ridge  connects  the  two  cusps  and 
all  the  surfaces  are  similar,  though  the  lingual  surface  is  larger. 

The  inferior  first  molar  (Fig.  i,  n,  p.  22)  is  usually  the  largest 
tooth  of  the  lower  jaw.  The  broad,  grinding  surface  supports 
five  cusps,  three  buccal  and  two  lingual,  or  they  may  be  de- 
scribed as  two  buccal,  two  lingual  and  one  distal.  The  mesio- 
buccal  cusp  is  the  largest  and  the  disto-buccal  the  smallest,  the 
other  three  are  subequal. 

A  fissure  extends  across  this  surface  from  a  point  near  the 
mesial  border  to  the  disto-buccal  cusp,  and  from  this  point  two 
fissures  run,  one  between  the  middle  buccal  and  the  disto- 
buccal  cusp,  the  other  between  the  disto-buccal  and  disto-lin- 
gual  cusps.  A  fissure  running  from  the  one  first  mentioned 
passes  nearly  to  the  lingual  border  dividing  the  two  lingual 
cusps,  and  another  passes  toward  and  often  through  the  buccal 
border  behind  the  mesio-buccal  cusp. 

The  buccal  surface  is  broad  and  much  rounded  off  at  its 


22 


OPERATIVE    DENTISTRY. 


upper  portion.  Across  this  surface  from  above  downward 
passes  a  groove,  near  the  middle  of  which  a  pit  is  often  found. 

The  hngual  surface  is  more  prominent  near  the  grinding 
surface  and  usually  smooth. 

The  proximal  surfaces  are  broad  and  rounded  above  and 
flattened  below. 

The  transverse  section  at  the  neck  is  nearly  square  with 
rounded  angles. 

There  are  two  roots,  a  mesial  and  a  distal ;  the  latter  being 


subcylindrical,  while  the  mesial  is  very  much  flattened  and 
grooved,  and  both  are  usually  curved  backward. 

Inferior  Second  Mo/ar(Fig.  i,  o,  p.  22). — This  has  a  grinding 
surface  which  is  very  nearly  square,  with  four  cusps  nearly  equal 
in  size.  The  groove  which  separates  the  mesial  and  distal 
cusps  sometimes  passes  through  the  border  to  the  buccal  sur- 
face, but  this  is  less  frequent  than  in  the  first  molar.  Occa- 
sionally the  second  molar  has  five  cusps,  the  conformation  of 
the  crown  being  similar  to  that  of  the  first  molar.     The  buccal 


THE    niXIDUOUS    AND    PERMANENT    DENTITIONS. 


23 


surface  recedes  toward  the  grinding  surface,  but  not  to  an  equal 
extent  witli  that  of  the  first  molar. 

The  lingual  rises  abruptly  to  its  angle  with  the  grinding 
surface. 

For  the  proximal  surfaces  and  roots  the  description  given 
for  the  first  molar  will  apply  to  this  tooth. 

Inferior  Third  Molar  (Fig.  i,  p,  p.  22). — This  varies  very 
much  in  regard  to  its  size  and  form,  but  usually  the  crown  is 
large  in  comparison  with  the  root,  and  frequently,  also,  in 
comparison  with  the  crowns  of  the  first  and  second  molars. 

The  grinding  surface  is  generally  of  an  irregular  outline, 
having  from   three  to  five  cusps.     All  the  other  surfaces  are 


Fig.  2. 


rounded  and  receding  toward  the  neck,  the  outline  of  which,  in 
transverse  section,  is  more  nearly  circular  than  that  of  the  two 
preceding  teeth.  The  root  is  usually  single,  grooved  on  each 
side,  short  and  curved  backward,  often  to  a  considerable  extent. 

The  Deciduous  Teeth  (Fig.  2). — In  general  terms,  these 
teeth  have  the  same  forms  and  characteristics  as  the  corres- 
ponding teeth  of  the  permanent  set. 

The  six  anterior  teeth  of  each  jaw  are  succeeded  by  those 
of  the  same  classes  as  themselves,  while  the  deciduous  molars 
are  the  prototypes,  not  of  the  bicuspids  which  succeed  them, 
but  of  the  permanent  molars. 

The  deciduous  teeth  are,  in  all  respects,  smaller  than  the  per- 


24  OPERATIVE    DENTISTRY. 

manent,  the  crowns  are  thick  and  short,  and  the  roots  of  the 
molars  are  much  flattened  and  strongly  divergent. 

The  enamel  of  these  teeth  terminates  abruptly,  which  gives 
the  effect  of  a  strongly-marked  constriction  at  the  neck.  So 
constant  is  this  characteristic  that  retained  deciduous  teeth  may 
always  be  recognized  by  passing  an  instrument  under  the  free 
margin  of  the  gum. 

In  structure  they  are  ordinarily  less  firm  and  dense  than  the 
permanent,  and  the  pulp  cavity  is  larger  in  proportion  to  the 
size  of  the  tooth. 

In  their  position  and  arrangement  there  is  seldom  any  irregu- 
larity, the  arches  being  even  and  rounded. 

DENTAL  CARIES. 

Dental  caries  was  formerly  supposed  to  be  identical  with 
caries  of  bone,  hence  the  use  of  the  term.  This  name  is  now 
in  almost  universal  use.  It  has  a  recognized  signification  and 
cannot  well  be  changed,  especially  as  our  present  knowledge 
of  the  pathology  and  causation  of  the  disease  cannot  furnish 
an  expressive  and  significant  name. 

Decay  is  another  term  in  common  use  to  express  the  same 
condition. 

The  disease  involves  the  hard  tissues  of  the  teeth  and  results 
in  the  destruction  of  a  part  or  the  whole  of  the  organ  attacked. 

In  every  country  of  the  world  and  in  all  ages  the  human 
teeth  have  been  thus  destroyed,  and  to  the  prevalence  of  this 
disease  alone  operative  dentistry  owes  its  rise  and  progress,  and 
at  the  present  time,  while  other  diseases  of  the  teeth  and  con- 
tiguous parts  require  attention,  dental  caries  claims  a  much 
larger  share  of  the  skill  and  labor  of  the  dentist  than  all  other 
affections  of  the  dental  apparatus. 

Clinical  History. — As,  in  a  perfectly  normal  condition, 
enamel  is  the  only  tissue  exposed  to  external  influences,  this 
must  necessarily  be  first  destroyed  and  removed  at  some  point 
before  the  dentine  is  reached  by  the  destructive  agencies,  which 
are  always  external.     If,  however,  a  portion  of  the  dentine  is 


DENTAL    CARIES.  2  5 

exposed,  as  a  result  of  imperfect  calcification,  fracture  or  wear, 
caries  may  have  its  beginning  in  this  tissue,  and,  in  cases  of 
recession  of  the  gum  exposing  the  cemcntum,  this  maybe  first 
attacked. 

For  convenience  of  study  the  progress  of  caries  is  divided 
into  three  stages,  superficial,  simple  and  complicated.  Super- 
ficial caries  affects  only  the  enamel.  Simple  caries  may  advance 
to  any  depth  and  extent  consistent  with  the  health  and  safety 
of  the  pulp,  while  complicated  caries  implies  a  diseased  condi- 
tion of  the  pulp  as  a  result  of  the  carious  process. 

Incipient  caries  of  the  enamel  is  marked  by  an  opaque, 
whitish  spot,  which  to  the  touch  of  an  instrument  will  be  found 
soft  and  friable.  This  soon  becomes  discolored  by  the  deposit 
of  extraneous  coloring  matter,  and  if,  as  is  sometimes  the  case, 
a  change  in  the  conditions  or  surroundings  of  the  tooth  should 
cause  the  decay  to  be  spontaneously  arrested,  the  enamel,  and 
if  the  decay  has  penetrated  the  dentine,  this  also,  will  usually 
become  very  dark  or  almost  black. 

Some  believe  that  the  color  of  the  disintegrating  tissue 
depends  mostly  or  wholly  upon  the  kind  of  acid  which  has 
acted  upon  it.  Three  kinds  of  caries  are  described;  first,  black, 
caused  by  sulphuric  acid.  This  is  not  as  frequent  as  the  other 
varieties.  Its  progress  is  very  slow  in  all  cases,  the  blackened 
tissue  remaining  quite  hard,  and  often  it  is  spontaneously 
arrested. 

Second,  brown  decay,  the  result  of  the  action  of  hydrochloric 
acid,  which  destroys  the  lime  salts  of  the  tooth,  leaving  the 
organic  portion  of  a  brown  color,  and  elastic,  leathery  consist- 
ence. This  progresses  more  rapidly  than  the  preceding,  and 
it  is  seldom  arrested  spontaneously. 

Third,  white  decay,  produced  by  nitric  acid,  which  rapidly 
destroys  both  the  mineral  and  the  organic  constituents  of  the 
tooth  so  that  they  are  readily  washed  away,  the  cavity  being 
usually  filled  with  extraneous  matter. 

Recent  researches  by  Dr.  Miller  seem  to  show  lactic  acid  to 
be  the  principal  agent  in  the  production  of  caries. 

3 


26  OPERATIVE    DENTISTRY. 

In  practice,  tissue  that  has  been  partially  or  wholly  decalci- 
fied will  be  found  of  all  possible  variations  of  color  and  con- 
sistency ;  these  variations  being  the  effect  of  the  combined 
action  of  the  destructive  agencies,  or  of  other  conditions,  as 
length  of  time,  quality  of  the  tooth- substance,  condition  of  the 
mouth  or  habits  of  the  individual. 

As  caries  progresses,  the  cavity  assumes  one  of  two  gen- 
eral forms,  becoming  either  broad  and  shallow,  with  no  well- 
defined  walls  or  orifice,  or  else  narrow  and  penetrating,  enlarg- 
ing within  the  dentine  and  extending  toward  the  pulp,  while 
the  opening  in  the  enamel  remains  comparatively  small. 

Certain  surfaces  of  the  teeth  are  specially  liable  to  be  attacked 
by  caries,  this  liability,  in  each  case,  depending  mostly  upon 
the  form  of  the  tooth  and  its  relation  to  other  teeth. 

Of  the  incisors  and  cuspids  the  proximal  surfaces  are  the 
most  frequently  affected,  and  next  the  labial  surface  at  the  mar- 
gin of  the  gum.  If  a  pit  exists  on  the  palatal  surface,  this  is 
frequently  the  seat  of  caries. 

The  bicuspids  are  also  most  frequently  attacked  on  the  prox- 
imal surfaces;  secondly,  in  the  pits  or  fissures  on  the  grinding 
surface ;  and,  thirdly,  the  buccal  surfaces  at  the  margin  of  the 
gum. 

The  molars  decay  most  frequently  in  the  fissures  of  the 
grinding  surface;  secondly,  on  the  proximal  surfaces;  and 
thirdly,  on  the  buccal,  in  the  pit  upon  this  surface,  or  at  the 
gum  margin,  and  lastly  on  the  lingual  surfaces. 

Decay  upon  any  point  of  the  surface  of  a  tooth  may  result 
from  defective  structure,  or  from  special  causes. 

The  tooth  most  subject  to  decay  is  the  lower  first  molar  of 
either  side,  and  next  to  this  the  upper  first  molar.  The  lower 
incisors  and  cuspids  are  the  least  liable  to  decay. 

Present  knowledge  of  the  subject  does  not  warrant  any 
definite  statement  respecting  the  relative  liability  to  decay  of 
the  other  teeth. 

Causation. — The  predisposing  causes  are  both  general  and 
local.     The  former  have  reference  mainly  to  systemic  condi- 


WORKING    STEEL.  2/ 

tions,  as  impaired  health  from  any  cause,  especially  affections 
of  the  nervous  and  digestive  systems,  and  the  state  of  the 
bodily  functions  at  different  periods  of  life. 

Local  causes  have  reference  to  organization,  calcification  and 
environment  of  the  teeth,  these  depending  largely  upon  the 
food,  occupation  and  habits  of  life  of  the  individual. 

Acids  undoubtedly  act  as  the  primary  exciting  cause  of 
decay  of  the  teeth,  though  many  other  factors  are  concerned, 
especially  microorganisms  and  inflammation,  or  a  process 
closely  allied  to  this.  For  the  discussion  of  the  "  theories  of 
decay "  the  student  is  referred  to  larger  treatises  and  the 
periodical  literature  of  the  subject. 

WORKING  STEEL. 

Very  often  an  instrument  of  peculiar  form  is  needed  for  a 
special  case;  it  is  therefore  very  important  that  every  operator 
should  be  able  to  make  such  instruments  as  necessity  requires, 
and  the  following  directions  will  enable  him  to  do  so. 

A  worn  excavator  is  the  ever-ready  material  for  this  purpose. 
Heat  to  a  cherry  red,  and  hammer  it  upon  the  anvil  toward  the 
form  desired  only  as  long  as  it  will  readily  yield.  Repeat  the 
heating  and  hammering  until  the  desired  form  is  obtained. 
Heating  hotter  than  a  cherry  red  or  hammering  when  too  cool 
injures  the  steel.  Bend  the  point  to  the  form  desired  and  reduce 
to  proper  size;  form  the  edge  by  filing  and  grinding.  Smooth 
and  polish  with  emery,  stone,  pumice  and  rouge ;  the  instru- 
ment is  then  ready  for  the  process  of  hardening  and  tempering. 

To  obtain  the  proper  temper  for  a  good  cutting  edge,  the 
instrument  must  first  be  heated  to  a  bright  red  heat  and  sud- 
denly cooled  by  plunging  into  cold  water  or  other  cold  liquid. 
This  will  give  to  the  steel  a  silvery  whiteness,  and  render  it  so 
hard  that  a  sharp  corner  will  readily  scratch  glass;  this  should 
be  the  test  of  the  hardening.  Make  the  part  to  be  tempered 
clean  and  bright  with  fine  emery  or  by  other  means ;  heat  the 
instrument  slowly  well  up  on  the  shank,  and  allow  the  heat 
gradually  to  approach  the  point;  the  blue  and  straw  colors  will 


28 


OPERATIVE    DENTISTRY, 


be  seen  to  run  down  on  the  shank  as  the  heat  progresses. 
There  will  be  all  the  shades  of  blue  from  very  dark  to  very 
light,  and  joined  to  this  a  dark  straw  color  which  will  terminate 
in  a  very  light  straw. 

The  dark  blue  represents  a  soft  steel,  the  medium  and  light 
blue  a  spring  temper;  the  dark  straw  shows  a  soft  cutting  edge 
and  the  pale  straw  a  very  hard  cutting  edge. 

When  the  instrument  is  tempered,  the  position  of  the  colors 
should  be  as  marked  in  Fig.  3. 

A  thick  edge  will  bear  a  much  harder  temper  without  break- 
ing than  a  thin  edge,  consequently  the  thick  edge  may  be  left 
a  very  pale  straw,  while  the  thin  edge  must  be  a  little  darker. 

For  drawing  the  temper  of  small  instruments,  the  flame  of 


a,  Point  where  heat  is  applied. 
/-,  Dark  lilue. 

c,  Light  blue. 

d,  Dark  straw. 

e,  Light  straw. 


the  annealing  lamp  is  sufficient.  For  hardening,  a  greater  heat 
is  required. 

The  shank  of  the  instrument  should  be  of  spring  temper, 
and  some  practice  will  be  necessary  to  obtain  a  good  spring 
temper  throughout  the  length  of  the  shank  and  avoid  reduc- 
ing it  too  low  in  some  places. 

A  weak  solution  of  sulphuric  acid  will  in  a  few  moments 
remove  from  the  instrument  all  of  the  coloring  caused  by 
tempering. 

Sharpening  Instrjuncnts. — The  rough  grinding  may  be  done 
with  a  fine  corundum  wheel  well  moistened,  to  avoid  heating 
the  in.strument,  after  which  an  Arkansas  oil  stone  should  be 
used  for  giving  a  fine  edge. 


WORKINc;    STEEL.  29 

"  Instructions  for  Making  Instruments  from  Piano- 
Wire  for  the  Removal  of  the  Contents  of  Pulp-Canals. 
— Tlic  very  best  (juality  of  piano-wire,  of  No.  20  or  No.  22 
standard  wire  or  jilatc  gauge,  should  be  used. 

"  It  should  be  cut  into  lengths  of  three  inches,  and  should  then 
be  filed  down  to  the  required  size  and  taper.  The  wire  should 
commence  to  taper  at  one  and  one-half  inches  from  the  point, 
while  the  last  half  inch  should  be  of  nearly  uniform  size. 

"  Three  sizes  of  these  instruments  are  all  that  are  needed,  and 
they  should  measure,  at  the  smallest  diameter,  0.007,  o.oio,  and 
0.013  of  an  inch,  respectively,  before  the  hook  is  made;  with 
the  hook  they  should  measureo.oio,  0.014,  and  0.0 17  of  an  inch. 

"When  the  wire  is  reduced  to  the  required  size,  the  hook  is 
to  be  formed  by  placing  the  wire  on  an  anvil,  or  other  smooth 
hard  surface,  and  holding  the  smooth  edge  of  a  thin  knife  blade 
upon  it,  near  the  end  of  the  wire,  when  the  wire  is  to  be  drawn 
up  sharply  and  tightly,  making  a  hook  with  a  somewhat  acute 
angle.  The  hook  can  then  be  honed  down  to  the  desired 
length. 

"  The  instruments  should  then  be  fastened  in  small  handles, 
which  can  be  procured  of  dealers  in  watchmakers'  supplies  for 
twenty-fiv^e  cents  a  dozen,  or  they  can  "be  easily  made  from  any 
soft  or  hard  wood. 

"  Piano-wire  should  never  be  heated,  and  should  be  filed 
lengthwise." 

*'  Method  of  Rendering  Swiss  Broaches  of  Spring  Tem- 
per.— To  draw  Swiss  broaches  to  a  spring  temper  they  should 
be  placed  on  a  steel,  iron,  or  brass  plate,  one-eighth  of  an  inch 
in  thickness  and  three  inches  square.  This  should  be  held  by 
phers  or  forceps  over  the  flame  of  a  spirit  lamp,  and  be  kept 
continually  moving  over  it,  so  as  to  keep  the  plate  as  uniformly 
heated  as  possible.  The  broaches  should  be  watched  very 
carefully,  and  when  they  become  of  a  dark-blue  color  they 
should  be  dropped  in  cold  water." 

"  Method  of  Rendering  Swiss  Broaches  Completely  Soft. 
— A  piece  of  tin  may  be  cut  and  bent  so  as  to  make  a  rough 


30 


OPERATIVE    DENTISTRY. 


box,  two  and  one-half  inches  long  by  one  inch  square.  This 
should  be  filled  half  full  of  slaked  lime,  and  the  broaches — one, 
two,  or  three  dozen — placed  in  the  middle  of  the  lime,  and  the 
box  then  filled  over  them.  This  should  then  be  heated  to  a 
red  heat,  either  with  the  blowpipe  or  in  a  stove  fire,  and  then 
allowed  to  gradually  cool.  They  can  then  be  polished  by 
holding  them  flat  on  a  hard  smooth  surface  and  rubbing  them 
lengthwise  with  oo  emery  paper. 

"  Broaches  rendered  soft  in  this  manner  are  very  tough  and 
can  hardly  be  broken,  and  are  safer  for  use  in  places  difficult 
of  access  than  those  of  spring  temper. 

"They  should  be  fastened  in  small  handles,  or  used  in  the 
universal  broach  holder."-* 

INSTRUMENTS. 
The  number  and  variety  of  dental  instruments  now  manu- 
factured is  so  great  that  it  would  be  impossible  to  describe  or 
name  them  in  this  work,  and  a  description  of  important  classes 
only  will  be  attempted. 

Fig.  4. 


Excavators  are  made  in  great  variety  of  form,  the  principal 
of  which  are  hatchets,  hoes  and  spoons. 

We  have  the  following  in  various  siz^s : — 

The  right-angle  hatchet  (Fig.  4),  the  obtuse-angle  hatchet 
(Fig.  S),  the  acute-angle  hatchet  (Fig.  6),  hoes  of  the  various 


*  «  Management  of  Pulpless  Teeth."     Chicago,  1887. 


INSTRUMENTS. 


31 


sizes  (Fig.  7),  spoons  (Fig.  8).  Fig.  9  shows  a  style  of  exca- 
vator in  which  the  cutting  edge  is  brought  on  a  hne  with  the 
handle,  thus  working  with  much  greater  ease  and  steadiness 
than  the  ordinary  style. 


Fig.  6. 


Fig.  7. 


Fig. 


All  these  instruments  are  also  made  with  two  angles  in  the 
shank.  (Fig.  10.)  They  are  also  made  in  pairs,  curved  to  cut 
right  and  left. 


Fig.  10. 


Fig.  9. 


Chisels  of  various  sizes  and  forms  are  useful  in  breaking 
down  the  edges  of  cavities,  dressing  down  the  exposed  edges 
of  enamel  and  removing  decayed  dentine. 

A  class  of  these  instruments,  known  as  Head's  Excav^ators 


32 


OPERATIVE    DENTISTRY. 


— shown  in  Fig.  ii — gives  a  variety  of  forms  which  enables 
the  operator  to  cut  in  every  direction. 


Fig.  II. 


(f  i  e 


r\  fTo  /^  /\  n 


Another  class  are  known  as  hard  bits,  the  cutting  edges  of 
which  are  right  angles,  and  the  temper  very  hard.  They  are 
very  effective  in  dressing  away  enamel,  as  they  cut  smoothly 
and  evenly  without  chipping.     They  are  shown  in  Fig.  12. 


Fig.  12. 


Fig.  13. 


Fig.  14. 


Each  has  eight  cutting  edges,  and  each  edge  will  cut  in  two 
directions. 

Two  forms  of  drills  are  illustrated :  the  flat,  square-pointed 
and  the  spear-pointed. 

The  flat,  square -pointed  are  especially  useful  for  drilling 
retaining   pits    (Fig.    13).     The   spear-pointed    (Fig.    14)   are 


INSTRUMENTS. 


33 


adapted  for  drilling  enamel  and  dentine,  to  reach  the  pulp 
chamber,  and  for  other  purposes. 

These  are  made  in  various  sizes — some  quite  small,  and  with 
long,  spring-tempered  shanks,  which  allow  them  to  be  used  in 
canals  inaccessible  to  straight  instruments  that  are  not  flexible. 

Burs  are  made  in  great  variety  of  forms  and  sizes,  as 
shown  in  Fig.  15.  They  are  known  as  round,  wheel,  cone, 
inverted  cone,  bud,  fissure  and  oval.  These  are  made  both 
for  use  as  hand  instruments  and  for  the  engine. 

Via.  15. 


Instruments  for  Pulp  Canals. — These  consist  of  broaches, 
drills,  reamers  and  pluggers.     Broaches  for  removal  of  the 


Fig.  16. 


pulp  are  of  various  forms,  as  the  barbed  broach  (Fig.  16),  the 
fine,  spring-tempered  hook  broach  (Fig.  17). 


34 


OPERATIVE    DENTISTRY. 


Fine  hook  broaches  are  also  made  of  fine  piano-wire,  by 
fihng  down  without  changing  the  temper.  Broaches  are  also 
made  of  an  alloy  of  platinum  and  iridium,  which  are  useful 
for  medication,  as  they  do  not  corrode. 

Drills  for  use  in  the  pulp  canals  should  be  of  small  size  and 
flexible.  The  points  may  be  square,  spear-pointed,  or  enlarged 
in  the  form  of  a  bud  and  with  sharp  edges  for  cutting,  as 
shown  in  Fig.  i8. 

Reamers  for  nerve  canals  are  made  pointed  and  in  the  form 
of  a  square,  triangle,  or  half  cone  (Fig.  19). 


Fig.  18. 


Fig. 


Fig.  20. 


^  l^ 


The  smaller  instruments  should  have  flexible  shanks. 
Those  made  from  piano-wire  are  excellent. 

Pluggers  for  pulp  canals  should  be  of  long  taper,  spring- 
tempered  and  small  enough  to  reach  the  deepest  portion  of 
the  canal.     Both  straight  and  curved  are  needed  (Fig.  20). 

Instruments  for  Cleaning  Teeth. — Instruments  for  the 
removal  of  calcareous  deposits  from  the  teeth  are  called 
scalers.  They  are  of  various  forms,  which  may  be  best  un- 
derstood by  reference  to  the  following  cuts  : — 

The  essential  part,  of  the  instrument  is  a  sharp  edge  for 
scraping  the  deposit  from  the  teeth. 


INSTKLMENTS. 


35 


Fig.  21  illustrates  the  Abbott  set  of  scalers. 
Fig.  22  shows  the  Gushing  scalers,  which   arc  formed  for 
removing  the  deposit  by  pushing. 


Fk;.  21. 


Fig,  22. 


Fig.  23. 


The  right-angle  edge, which  is  found  on  the  hard  bit  and  on  the 

sickle-shaped  scalers  of  several  sets,  is  effactive  for  this  purpo.se. 

Fig.  23  represents  a  modification  of  one  of  Riggs'  instru- 


36 


OPERATIVE    DENTISTRY. 


merits.  It  should  be  made  very  hard,  with  square,  sharp 
edges,  like  the  hard  bits.  It  is  a  universal  instrument,  cutting 
in  all  directions. 

Instruments  for  Filling. — Instruments  for  filling  are  made 
in  such  variety  of  form  and  style  that  it  would  be  quite  im- 
possible to  describe  them  all.  The  essentials  which  all  should 
possess  are  described,  leaving  the  choice  of  form  and  style  of 
instrument  to  the  operator. 

Instruments  for  filling  with  cements  consist  of  a  flexible 
spatula  for  mixing  (Fig.  24),  thin,  flat  instruments  for  inserting 
the  filling  (Fig.  25),  and  some  broader  and  smooth,  as  well  as 
thin,  for  finishing  (Fig.  26). 

Fig.  24. 


Fig. 


Fig.  26. 


Fig.  27. 


Fig.  28. 


Fig.  29. 


Ball  burnishers  are  sometimes  useful  for  packing  the  cement 
and  for  finishing. 

For  packing  amalgam,  instruments  of  various  forms  and 
sizes,  with  smooth  ojr  serrated  oval  surfaces,  are  best  adapted 
(Figs.  27,  28). 


INSTRLMKNTS. 


37 


Flat  burnishers  of  different  sizes,  some  thin,  some  bent 
on  the  edge  and  some  on  the  flat  (Fig.  29),  are  also  useful. 
These  two  classes  of  instruments  will  be  sufficient  for  all 
cases. 

Pluggers  for  Gold. — For  packing  non-cohesive  gold,  instru- 
ments acting  upon  the  wedge  principle  are  ftsed.  The  points 
are  long  and  tapering  in  form,  terminating  in  a  wedge-shaped 
edge  (Fig.   30). 

Fk;.  30. 


These  are  used  entirely  with  hand  pressure. 

In  finally  condensing  the  surface  of  the  filling,  a  larger 
instrument  is  used,  with  a  broad,  flat  surface. 

For  packing  cohesive  gold  foil,  pluggers  having  either  flat 
or  oval  surfaces  are  used. 

These  instruments  are  made  in  great  variety  to  meet  the 
requirements  of  cavities  of  all  sizes  and  in  all  positions.  The 
faces  are  serrated  to  prevent  slipping  and  to  keep  the  surface 
of  the  gold  a  little  roughened.  Two  grades  of  serrations  are 
used,  the  very  fine  and  the  medium.  The  coarse  serrations 
formerly  used  have  been  discarded.  These  instruments  are 
made  suitable  to  be  used  either  with  hand  pressure  or  the  hand 
mallet,  and  also  with  the  automatic  and  electric  mallet.  The 
following  figures  illustrate  a  variety  of  forms  in  common 
use : — 


Fig.  31. 


38 


OPERATIVE    DENTISTRY. 

Fig    32. 


Frc.  33. 


Clamps  are  an  important  auxiliary  in  the  use  of  the  rubber 
dam.  They  serve  to  hold  the  rubber  upon  teeth  which  have 
very  short  crowns  or  which  are  far  back  in  the  mouth,  so  that 
the  strain  of  the  cheek  or  tongue  is  likely  to  draw  it  off,  or  in 
any  situation  in  which  it  is  impracticable  or  undesirable  to 
apply  the  ligature.  They  also  serve  to  hold  the  rubber 
away,  and  thus  afford  a  better  view  of  the  tooth  operated 
upon. 

Very  many  different  forms  have  been  devised  for  the  differ- 
ent classes  of  teeth  and  of  cavities,  and  the  student  must 
select  such  as  will  best  serve  his  purpose. 


INSTRUMENTS. 


39 


The  following  figures  show  several  sets  of  the  more  desir- 


able forms 


Fig.  34. 


^m- 


Fig.  34  rtpresents   How's  cervix  clamp.     Its  purpose,  con- 
struction and  adjustment  are  plainly  shown  in  the  cuts. 

Fig.  35. 


Dr.  W.  W.  Evans'  lieaked  Molar. 
Fig.  36. 


Fig.  37. 


Dr.  E.  C.  Moore's. 


Fig.  38. 


Original  Allan — Plain. 


40 


OPERATIVE    DENTISTRY. 
•  Fig.  40. 


Dr.  Delos  Palmer's  Set. 


INSTRUMENTS. 


41 


42 


OPERATIVE    DENTISTRY. 


Fig.  43. 


Fig.  45. 


I.  Inferior  six-year  molar  and  canine.  2.  Cavities  of  decay. 
3.  The  rubber  dam  applied.  4.  The  clamps  holding  the 
dam  in  place,  making  visible  and  keeping  dry  the  cavities 
while  impacting  the  gold. 


Fig.s.  43,  44,  45  show  Dr.  D.  B.  Freeman's  cervix  clamp. 

Fig.  42  shows  the  Brewer  universal  forceps,  which  is  adapted 
to  all  clamps,  with  few  exceptions. 

Other  forceps  may  be  obtained  for  clampfi  of  special  form. 

Burnishers  for  use  upon  gold  fillings  are  sufficiently  de- 
scribed by  the  illustrations. 

Fig.  46. 


Fig.  46  represents  three  of  the  most  important  general  forms. 


INSTRUMENTS. 


43 


Finishing  instruments  consist  of  files  and  burnishers.  Fig. 
47  shows  Smith's  proximal  trimmers.  Numerous  appliances, 
in  addition  to  these,  are  used,  which  are  mentioned  under 
accessories. 

In   some  cases  the  thin,  flat,  separating  file  is  useful.     A 


Ku;.  47. 


Fig.  48. 


thin  instrument,  with  a  sharp  knife  edge  (Fig.  48),  is  useful  to 
dress  away  the  overhanging  gold  at  the  cervical  wall.  A 
chisel  or  hard  bit  is  also  often  effective. 

Finishing  burs,  corundum  points,  wood,  leather  and  rubber 
points  and  disks  are  used  almost  exclusively  with  the  engine. 


Fig.  49  shows  a  few  sizes  of  the  more  important  forms  of 
finishing  burs. 

The  Dental  Engine. — The  dental  engine  has  become  an 
almost  indispensable  aid  to  most  operators.  The  essential 
parts  of  the  engine  are  the  hand-piece  and  the  arm,  the  latter 


44 


OPERATIVE    DENTISTRY. 


either  flexible  or  jointed,  making  it  possible  to  use  a  bur  or 
drill  in  any  direction. 

The  S.  S.  White*  engine  has  the  flexible  arm,  and  the  Bon- 
will  and  the  Shaw  engines  have  the  jointed  arm,  the  last 
having  a  flexible  portion  next  the  hand-piece.  This  arm  is 
attached  by  suitable  mechanism  to  a  foot-power  or  to  a  water 
or  electric  motor. 

The  Morrison  suspension  engine  is  also  in  use.  The  power 
for  operating  this  is  transmitted  by  a  long  belt  over  pulleys  to 


Fig.  50. 


the  engine,  which  is  suspended  over  the  operating  chair. 
When  used,  the  hand-piece  is  drawn  down  to  the  mouth  of 
the  patient,  and  when  not  in  use  it  is  raised  by  weights  or 
springs,  so  arranged  as  to  hold  it  suspended. 

There  are  two  forms  of  hand-piece.  One  is  the  universal 
chuck,  which  will  carry  any  instrument  of  the  size  ordinarily 
used  for  the  engine.  For  the  other  form  of  hand-piece,  in- 
struments must  be  especially  fitted. 

Improvements   and  changes  are   being  constantly  made  in 


Fig.  51. 


Fig.  52. 


■HEQ 


engines  and  hand-pieces,  and  it  is  impracticable  to  describe  or 
mention  them  all. 

In  addition  to  the  instruments  already  described  for  use  with 
the  dental  engine.  Dr.  Robert  Huey's  screw-headed  mandrel 
(Fig.  50)  is  useful  for  carrying  disks  of  rubber,  corundum, 
or  sand  paper,  and  also  Klump's  screw-clamp  porte  polisher 
(Fig.  51)  for  carrying  points  of  wood  or  corundum  for  grind- 
ing or  polishing. 

Fig.  52  shows  a  mandrel  useful  for  leather  disks. 


INSTRUMENTS. 


45 


The  right-angle  and  acute-angle  attachments  render  the  bur 
or  drill  applicable  in  m^ny  places  inaccessible  to  the  straight 
hand-piece. 

The  disk  carrier  (Fig.  53)  is  also  a  valuable  attachment,  the 
fixed  angle  of  the  instrument  giving  different  directions  to  the 
disk  as  the  hand-piece  is  turned,  thus  'making  the  disk  appli- 


FlG    53. 


cable  in  many  places  which  could  not  be  reached  by  the 
straight  mandrel. 

The  general  forms  of  disks  are  shown  in  Fig.  54. 

Small  wheels  for  the  engine  are  now  made  of  corundum 
specially  prepared  and  baked  in  a  furnace  at  a  very  high  tem- 
perature. They  are  so  hard  as  not  to  be  perceptibly  worn  in 
grinding  the  teeth,  and  they  are   not  affected   by  any  heat 


Fig.  54. 


arising  from  friction.  Small  stones  for  the  engine  are  also 
made  of  the  same  material. 

Disks  of  hard  and  of  soft  rubber  are  also  used  for  carry- 
ing powder  for  polishing  the  natural  teeth  and  for  finishing 
fillings. 

Points  of  corundum,  stone,  wood,  rubber  and  leather  are 
made  in  great  variety  of  forms  for  finishing  and  polishing. 


46  OPERATIVE    DENTISTRY. 

Many  other  instruments  and  appliances  are  indispensable, 
and  are  mentioned  in  connection  with  the  operations  requiring 
them.  As  they  may  be  so  readily  seen  at  dental  depots,  any 
description  of  them  here  seems  unnecessary. 


THE  DENTIST  HIMSELF. 

The  appearance  of  the  operator  and  his  treatment  of  the 
patient  are  very  important,  and  largely  promote  or  hinder  his 
success. 

Remember  that  "  order  is  Heaven's  first  law,"  and  "  cleanli- 
ness is  next  to  godliness." 

Be  master  of  yourself  Control  the  temper  under  all  circum- 
stances. Be  kind  and  sympathetic  but  firm  and  self-respecting, 
dignified  but  not  distant,  and  tolerant  of  human  weakness,  both 
mental  and  physical. 

The  operating  room  should  be  neat,  orderly,  well-lighted 
and  airy. 

The  north  gives  the  steadiest  and  clearest  light,  the  south- 
erly aspect  is  the  most  healthful,  while  the  western  sky  affords 
the  longest  day.  ' 

When  operating  by  direct  sunlight,  a  white  Holland  shade 
will  so  soften  the  light  as  to  make  it  agreeable,  and  yet  it 
remains  effective.  If  the  shade  be  placed  outside  the  window, 
it  affords  circulation  of  air  between  it  and  the  window,  and  thus 
keeps  the  heat  from  the  room.  A  white  awning  serves  the 
same  purpose,  but  shuts  out  more  light. 

The  operating  case  should  be  conveniently  placed  and  of 
sufficient  size  to  allow  of  a  convenient  arrangement  of  the 
instruments,  each  instrument  or  class  of  instruments  in  its 
place. 

Every  instrument  should  be  kept  clean,  free  from  rust  and 
well  polished. 

Observe  scrupulous  cleanliness  about  the  spittoon.  Wash 
frequently,  deodorize  and  disinfect.  A  weak  solution  of  sul- 
phate of  copper  is  an   inexpensive  and  effective   disinfectant. 


MANNER    OF    HOLDING    INSTRUMENTS.  47 

Other  excellent  disinfectants  are  Piatt's  chlorides  or  perman- 
ganate of  potash. 

Give  careful  attention  to  personal  cleanliness,  especially  the 
hands.  Wash  them  frequently,  using  the  best  toilet  soap. 
Keep  the  nails  pared  short  and  scraped  clean.  When  a  grimy, 
rough  or  chapped  condition  of  the  hands  obtains,  give  them  a 
thorough  washing  in  soft  water  with  the  free  use  of  carbonate 
of  soda ;  partially  dry  the  hands  and  apply  glycerine  and 
rose-water,  rubbing  well ;  then  rinse  in  clear,  cold  water  and 
wipe  dry.  This  leaves  the  hands  perfectly  clean  and  soft 
and  promotes  healing. 


MANNER  OF  HOLDING  INSTRUMENTS. 

A  few  general  principles  which  the  student  should  fully 
comprehend,  are  concerned  in  the  holding  of  instruments. 

First,  the  instrument  should  be  grasped  firmly,  so  as  to  be 
fully  under  control. 

Second,  the  hand  should  have  some  firm  support  to  render 
the  motions  of  the  instrument  accurate  and  steady.  This  sup- 
port is  best  obtained  by  resting  the  thumb  or  the  third  or 
fourth  finger  upon  such  teeth  or  other  parts  as  will  best  accom- 
modate the  operation. 

The  instrument  is  held  either  between  the  thumb  and  the  first 
and  second  fingers,  as  a  pen  is  held,  as  in  Fig.  55,  or  grasped 
in  the  palm  of  the  hand,  as  shown  in  Fig.  56. 

When  held  like  a  pen,  the  fingers  which  hold  the  instru- 
ment should  be  kept  free  from  the  third  finger,  which  forms 
the  support,  so  that  the  motion  may  not  be  impeded  by 
contact. 

The  student  is  advised  to  practice  a  wide  range  of  motion, 
so  that  he  may  operate  with  ease  in  any  part  of  the  mouth. 

Fig.  57  shows  an  effective  range  of  six  inches,  with  the  point 
of  the  instrument  one  inch  from  the  second  finger. 


48 


OPERATIVE    DENTISTRY, 
Fig.  55. 


£Ty 


^'^^^^^cgj 


Fig.  56. 


xy\>-^. 


">>v 


MANNER    or    HOLOINf;    INSTRUMENTS. 


49 


50 


OPERATIVE    DENTISTRY. 


EXAMINATION  OF  THE  MOUTH. 

The  instruments  required  for  examination  are  the  mouth 
mirror  and  suitable  explorers  (Fig.  58),  and  diagram  (Fig.  59) 
for  recording. 

Fig.  59  is  a  modification  of  those  proposed  by  Dr.  Perry 
and  Dr.  McKellops. 

Listen  attentively  to  the  patient's  story ;  the  history  of  a  case 
is  often  important.  Respect  the  patient's  fear  and  dread,  and 
avoid  the  sudden  probing  of  a  sensitive  tooth ;  make  haste 
slowly  at  first. 

Note  the  age,  temperament  and  condition  of  the  patient. 
Observe  the  number,  arrangement,  form  and  quality   of   the 


Fig.  58. 


teeth,  and  the  general  condition  of  the  gums  and  mucous  mem- 
brane and  the  appearance  and  reaction  of  the  saliva.  Notice 
any  existing  complication,  as  local  inflammation,  ulceration, 
abscess  or  tumors.  Record  all  the  facts  observed  briefly,  but 
accurately,  for  future  reference. 

Finally,  examine  the  teeth  with  reference  to  the  location 
and  extent  of  caries  or  other  defects  and  operations  needed. 
The  results  of  the  examination  may  be  indicated  by  marks 
and  abbreviations,  and  such  remarks  as  may  be  necessary  to  a 
complete  understanding  of  the  case. 

Some  system  should  be  adopted  in  order  that  the  examina- 
tion  may   be   made  complete   in  the  shortest  time,  and    it  is 


EXAMINATION    OF    TIIK    MOUTH. 

Flii.    Sy. 


5' 


52  OPERATIVE    DENTISTRY. 

recommended  to  begin  with  the  posterior  tooth  of  the  upper 
jaw  on  the  right  side  and  pass  around  to  the  same  position  on 
the  left  side,  then  commence  on  the  lower  jaw  and  examine  the 
lower  teeth  from  the  left  around  to  the  right.  It  will  be  found 
best  to  examine  all  the  surfaces  of  each  tooth  before  passing  to 
the  next. 

On  all  surfaces  except  the  proximal  the  sight  will  assist  the 
touch  in  detecting  cavities  of  decay.  For  proximal  surfaces 
the  pair  of  instruments  above  named  should  be  used,  pass- 
ing the  instrument  between  the  teeth  near  the  necks  and 
turning  the  point  toward  the  grinding  surface  and  against 
the  tooth  to  be  examined,  where  it  may  be  made  to  enter 
any  cavity  upon  that  surface.  For  the  contiguous  surface 
of  the  next  tooth  the  other  instrument  should  be  used  in 
like  manner. 

DEPOSITS  ON  THE  TEETH. 

Those  of  importance  are  salivary  calculus,  sanguinary  or 
serumal  calculus  and  green  stain. 

The  elements  of  salivary  calculus  are  present  in  the  saliva 
of  every  person.  Calculus  collects  upon  the  teeth  of  some  in 
large  quantities,  while  on  others  it  is  scarcely  perceptible. 

It  is  composed  of  earthy  salts  and  animal  matter.  The 
salts  are  principally  phosphate  and  carbonate  of  lime  and  mag- 
nesia. The  animal  matters  consist  of  fibrine,  fat,  epithelial 
scales,  food  and  saliva. 

The  proportions  of  constituents  vary  so  that  no  two  analyses 
give  the  same  result. 

Berzelius  gives : — 

Phospliate  of  lime  and  magnesia 79 

Salivary  mucus  and  salivine 13.5 

Animal  matter 7-5 

loo.o 
The  analysis  of  Vauquelin  and  Langier  gives:  — 

Phospliate  of  lime  and  a  little  magnesia 66 

Carbonate  of  lime 9 

Salivary  mucus,  including  plyalin 13 

Animal  matter 5 

Water  and  loss 7 

100 


DKPOsrrs  ON  thk   tf.eth.  53 

Bacteria,  also,  are  Ljencrally  present.  Calculus  varies  much 
in  color,  being  sometimes  white  or  yellowish,  at  other  times  of 
a  pale  or  dark  brown  color,  and  in  some  instances  black.  The 
color  and  hardness  have  a  direct  relation  to  eacli  other;  the 
white  is  very  soft  and  easily  removed,  the  black  is  the  hardest 
and  adheres  to  the  teeth  with  great  firnmess. 

Salivary  calculus  is  a  deposit  from  the  normal  secretions  of 
the  mouth, and  is  in  no  sense  a  pathological  production;  but  if 
allowed  to  remain  on  the  necks  of  the  teeth  it  will  produce 
changes  of  a  serious  nature  in  the  adjacent  tissues. 

This  deposit  collects  in  the  greatest  quantities  on  the  lingual 
surfaces  of  the  inferior  incisors  and  the  buccal  surfaces  of  the 
superior  molars,  these  localities  being  near  the  openings  of 
the  ducts  of  the  salivary  glands.  It  collects  on  all  the  teeth 
and  upon  every  part  of  crown  and  root,  even  to  the  apex  of 
the  root,  and  causes  neuralgic  pain  by  its  constant  irritation  of 
the  nerves  of  the  pericementum,  or  by  impinging  on  the  nerve 
of  the  pulp  at  the  foramen.  If  not  removed  it  will  accumulate 
in  great  quantities,  sometimes  nearly  covering  the  teeth  from 
sight. 

Calculus  has  no  effect  upon  tooth  substance,  but  to  the  gum 
with  which  it  is  in  contact  it  is  very  irritating,  causing  inflam- 
mation which  extends  to  the  pericementum  and  implicates 
the  alveolar  process,  causing  its  absorption.  It  produces  a 
morbid  condition  of  the  fluids  of  the  mouth  and  causes  fetid 
breath. 

A  green  or  brown  stain  collects  on  the  labial  surfaces  of  the 
teeth  near  the  gums,  especially  on  the  superior  incisors  of 
children  and  young  persons.  The  surface  of  the  enamel  under 
this  is  generally  found  rough  and  imperfect.  The  cause  and 
nature  of  this  stain  are  uncertain,  but  it  is  thought  by  Wedl 
and  others  to  be  a  fungous  growth,  the  result  of  neglect  of  the 
teeth. 

The  hard,  dark  deposit  found  upon  any  portion  of  the  roots 
of  teeth  is  described  as  sanguinary  or  serumal  calculus.  This 
is  the  result  of  inflammation,  and  is  deposited  from  the  serum 


54  OPERATIVE    DENTISTRY. 

of  the  blood  and  colored  with  the  hematin.  It  contains  a 
larger  proportion  of  mineral  matter  than  any  other,  and  is, 
consequently,  the  hardest. 


CLEANSING   TEETH. 

Cleansing  teeth  consists  in  the  removal  of  calculus,  stains 
and  any  other  foreign  matter  from  the  teeth,  leaving  the  sur- 
faces polished. 

Calculus  is  removed  with  sharp  steel  instruments,  so  formed 
as  to  be  readily  applied  to  every  part  of  each  tooth.  In  their 
use  care  should  be  taken  to  avoid  scratching  the  surfaces  of 
the  teeth.  The  square  edge  of  the  hard  bit  is  particularly 
well  adapted  to  this  purpose ;  it  is  very  effective  and  safe  and 
is  utilized  in  many  of  the  scalers  used.  The  instrument  is  held 
firmly  against  the  tooth  and  carried  along  parallel  with  the 
surface,  the  edge  clearing  the  calculus  before  it. 

The  scalers  described  in  the  chapter  on  instruments  will 
prove  excellent  in  skillful  hands. 

Dr.  Abbott's  set  is  well  adapted  for  general  practice,  as  they 
are  capable  of  so  wide  a  range  of  motion  and  application. 

Dr.  Cushing's  set,  especially  arranged  for  the  application  of 
the  pushing  force,  is  effective. 

Dr.  Harlan's  set  is  also  used  with  the  pushing  force,  and  are 
effective  instruments. 

A  Riggs  scaler  with  the  edges  of  the  hard  bit  is  an  admi- 
rable instrument,  and  will  be  found  an  effective  auxiliary  to 
any  set. 

To  remove  calculus  from  the  roots  of  teeth,  pass  a  thin, 
hoe-shaped  instrument  under  the  gum  beyond  it,  and  drawing 
toward  the  crown  of  the  tooth  bring  the  deposit  with  it,  or, 
using  instruments  constructed  for  the  pushing  force,  hold  the 
instrument  firmly  against  the  root  and  press  toward  the  apex 
until  the  deposit  is  loosened. 

A  second  or  third  sitting  is  advisable,  as  some  particles  of 
calculus  are  liable  to  be  left,  and  unless  removed  at  a  subse- 


CLEANSING    TEETH.  55 

quent  sittinf^,  will  form  a  nucleus  for  further  deposit.  These 
will  be  readily  detected  after  the  bleeding  has  ceased  and  the 
gum  healed.  At  the  subsequent  sittings,  whenaver  a  red  or 
blue  spot  or  line  remains  upon  the  gum,  a  speck  of  calculus 
will  be  found  beneath  it. 

After  the  calculus  is  removed,  polish  with  powdered  pumice 
applied  on  an  orange-wood  stick,  or  wood  point,  or  soft  rub- 
ber disk  in  the  engine,  followed  by  polishing  putty  (oxide  of 
tin)  or  chalk. 

To  remove  the  green  and  other  stains  from  the  teeth,  apply 
tincture  of  iodine  freely  and  then  polish  as  before.  The 
iodine  acts  upon  the  stains  and  they  are  then  easily  removed. 
Nothing  will  affect  the  stain  of  tobacco  smoke.  It  can  be 
removed  only  by  means  of  instruments  and  polishing. 

After  the  cleansing,  the  patient  should  be  advised  to  use 
tooth  powder  with  the  brush  at  least  once  a  day,  and  to  use 
the  brush  after  each  meal,  brushing  not  across,  but  always  , 
lengthwise  of  the  teeth  from  the  gums.  The  brushing  after 
meals  may  be  omitted  without  serious  results  if  the  toothpick 
is  used,  but  brushing  the  teeth  in  the  morning  and  on  retiring 
is  essential  to  the  welfare  of  the  organs.  The  use  of  the 
toothpick  after  a  meal  is  advisable  to  remove  particles  of  food 
from  between  the  teeth.  Care  should  be  exercised  to  avoid 
crowding  the  pick  between  the  necks  of  the  teeth  and  thus 
injuring-  the  gum. 

The  ubiquitous  wooden  toothpick  is  objectionable  on  account 
of  its  great  size,  which  renders  it  liable  to  injure  the  gum,  and 
the  liability  to  break,  leaving  pieces  to  irritate  the  gum. 

A  quill  sharpened  and  scraped  rather  thin  is  undoubtedly 
the  best. 

Dental  floss  silk  is  useful  and  effective,  but  great  care  is 
needed  not  to  carry  it  too  far  under  the  gums  and  injure  them. 
Properly  waxed,  it  is  a  very  convenient  article  for  the  purpose. 

Mastication  has  great  influence  on  cleanliness.  People  often 
form  a  habit  of  chewing  on  one  side  of  the  mouth  exclusively, 
which  is  quickly  shown  by  the  decided  uncleanliness  of  the 


56  OPERATIVE    DENTISTRY. 

neglected  side  and  the  nicely  polished  appearance  of  the  oppo- 
site side.  They  should  be  advised  to  correct  the  habit  and 
use  both  alike, 

SEPARATING  TEETH. 

Its  object  is  to  afford  room  for  examination  or  operation. 
This  may  be  accomplished  by  wedging  the  teeth  apart  or  by 
removal  of  substance.  The  wedging  may  be  done  by  wood, 
tape,  raw  cotton,  silk  or  linen  thread,  rubber,  wedge  forceps  or 
screw  separators. 

The  wood,  tape  or  cotton  is  used  by  first  inserting  a  thin 
portion  and  exchanging  at  intervals  of  twelve  or  twenty -four 
hours  for  thicker,  until  the  desired  space  is  obtained.  Cotton 
is  more  applicable  where  a  cavity  exists.  In  using  thread,  tie 
a  knot  in  it  and  pass  the  knot  between  the  teeth  and  tie  the 
thread  around  the  point  of  contact,  drawing  the  knot  between. 
This  method  is  suitable  only  v/hen  the  teeth  are  but  little  de- 
cayed. For  separating  with  rubber  take  fine  quality  French 
rubber  tubing  or  the  ordinary  rubber  bands,  cut  a  piece  from 
one-sixteenth  to  one-fourth  of  an  inch  in  length,  according  to 
force  required,  slit  the  tubing,  stretch  the  piece  between  the 
teeth  and  cut  off  the  free  ends.  The  elasticity  of  the  rubber 
will,  in  twenty-four  hours,  separate  the  teeth  sufficiently  for 
ordinary  purposes.  If  the  teeth  are  in  very  close  contact  a 
piece  of  rubber  dam  may  be  first  used..  Any  sharp  edges 
which  cut  the  rubber  must  be  smoothed.  Use  thin  rubber  and 
a  narrow  piece,  to  avoid  soreness.  Maintain  the  separation 
with  cotton  until  the  tenderness,  if  there  be  any,  disappears, 
before  operating. 

With  the  screw  separators  or  the  wedge  forceps  the  separa- 
tion may  be  made  in  from  five  to  thirty  minutes.  In  using 
the  former,  apply  and  turn  the  screws  until  they  press  firmly, 
and  after  waiting  a  few  minutes  repeat  until  sufficient  space  is 
obtained.  Figs.  60  and  61  show  Perry's  two-bar  separators 
with  wrench  for  turning  bars. 

These  separators  allow  the  light  to  be  thrown  unobstructed 


Fig.  6o. 


SEPAKATINd    TKIvTII. 
Kit;.  Ci. 


57 


upon  every  part  of  the  separated  surfaces.  Little 
arrows  stamped  upon  the  bars  indicate  the  direction 
in  which  they  are  to  be  turned  to  spread  the  sepa- 
rators. The  wrench  for  operating  them  is  double- 
end,  one  end  straight  and  the  other  bent  at  an 
angle  to  give  greater  facility  for  turning  the  bars  in 
different  positions. 


Fig.  62. 


Fig.  62  shows  the  separator  applied.  When  there 
is  a  tendency,  as  with  teeth  of  narrow  necks,  to 
slip  toward  the  gum,  wood  or  gutta-percha  props 
are  to  be  put  on  the  adjacent  teeth,  under  the 
bows,  to  prevent  them  from  tilting,  and  to    keep 


58 


OPERATIVE    DENTISTRY. 


the  points  from  being  forced  under  the  gums  while  the  teeth 
are  being  separated. 

Fig.  63  shows  Parr's  universal  screw  separator  and  wrench. 
The  cut  explains  the  manner  of  application. 

In  the  use  of  the  wedge  forceps  the  same  principle  should  be 
observed,  of  waiting  for  the  teeth  to  yield  to  the  pressure  already 
applied.  In  rapid  wedging  the  only  space  that  can  be  obtained 
safely  is  by  compressing  the  pericementum. 

For  immediate  separation  with  wedges  a  thin  piece  of  wood 
or   quill  is  introduced  between  the  teeth,  to  protect  the  gum. 


Fig.  63. 


Ml     Q    i' 


and  next  to  this  a  narrow  wedge  of  orange,  hickory  or  box- 
wood, so  formed  as  not  to  interfere  with  the  wall  of  the  cavity. 
These  are  allowed  to  remain  during  the  operation,  being  driven 
to  hold  the  space  gained  by  a  wedge  introduced  between  the 
points  of  contactor  near  the  cutting  edge,  by  hand  pressure  or 
mallet  force,  or  with  wedge  forceps.  The  wedging  should  be 
gradual,  to  allow  the  tissues  to  yield  to  the  pressure. 

After  gaining  the  space  required,  the  separating  wedge  should 
be  removed  and  the  projecting  portions  of  the  others  cut  off. 
If  the  space  should  be  required  for  another  sitting,  remove  the 
wedges  and  maintain  it  with  cotton  and  sandarac  varnish,  or 


OI'ENlN'f.    CAVITIES.  59 

gutta-percha.  Teeth  which  have  been  wedged  apart  soon  return 
to  their  normal  positions  when  left  to  themselves. 

Separating  by  cutting  away  the  tooth  substance  may  be  done 
with  chisels  or  "  hard  bits,"  and  when  this  is  resorted  to  the  teeth 
should  be  cut  away  toward  the  inside  of  the  mouth,  so  as  not 
to  disfigure  the  external  surfaces.  Separation  in  this  manner 
is  applicable  to  the  six  anterior  teeth  of  the  upper  jaw,  and 
is  recommended  for  them  only. 

It  is  not  necessary  nor  wise  to  cut  away  enough  to  expose 
or  endanger  the  dentine.  As  the  normal  point  of  contact 
near  the  cutting  edge  is  left  undisturbed,  the  separation  is 
made  permanent,  leaving  a  surface  which  is  self  cleansing  and 
which  causes  the  filling  in  proximal  cavities  to  present  within 


the  mouth,  subject  to  examination.  (Fig.  64.)  This  separation 
is  produced  by  dressing  away  the  proximo-palatal  angle  of  the 
tooth,  but  not  sufficiently  to  interfere  with  the  front. 

OPENING  CAVITIES. 

This  consists  in  enlarging  the  orifice  of  a  cavity  of  decay 
so  as  to  render  accessible  all  parts  of  the  cavity.  It  is  done 
by  cutting  down  the  enamel  walls,  and  by  removing  sound 
dentine  when  necessary. 

The  instruments  most  suitable  for  opening  crown  cavities 
are  chisels,  burs  and  excavators  ;  for  buccal  cavities,  excavators 
and  burs,  and  for  proximal  cavities  hard  bits,  chisels  and  burs. 

*  The  artist  has  exaggerated  this  somewhat.  It  indicates  too  much  cutting 
away. 


60  OPERATIVE    DENTISTRY. 

Ill  opening  proximal  cavities  in  superior  incisors  and  cus- 
pids, cut  away  the  palatal  wall  till  every  part  of  the  cavity  can 
be  seen  by  direct  sight  or  in  the  mirror.  A  few  prefer  to  cut 
away  the  labial  portion  of  the  enamel  and  expose  the  cavity 
to  direct  sight,  so  that  it  may  be  filled  from  the  front  and  with- 
out the  aid  of  a  mirror. 

Open  proximal  cavities  in  inferior  incisors  and  cuspids  from 
the  labial  surface,  but  distal  cavities  in  inferior  cuspids  may 
sometimes  be  opened  from  the  lingual  surface. 

After  the  teeth  are  separated  proximal  cavities  in  bicuspids 
and  molars  should  be  opened  toward  the  grinding  surfaces, 
except  when  small  and  near  the  gum.  In  such  cases  it  may 
be  better  to  open  from  the  buccal  surface.  If  decay  is  far 
advanced,  the  grinding  surface  should  be  cut  through.  When 
full  contour  is  desired,  separate  by  wedging,  open  the  cavities 
as  in  other  cases,  and  restore  the  contour  by  filling. 


REMOVAL  OF  DECAYED  DENTINE. 

This  is  accomplished  by  means  of  excavators,  chisels  and 
burs  of  various  forms  and  sizes,  cutting,  whenever  possible,  in 
a  direction  from  the  pulp,  as  this  causes  less  pain. 

In  deep  cavities,  allow  a  thin  layer  of  decalcified  dentine  to 
remain,  to  protect  the  pulp,  but  remove  all  softened  tissue  from 
the  borders  of  cavities,  and  all  discolorations  from  the  enamel 
or  near  it,  whenever  possible,  and  from  any  connecting  grooves, 
especially  in  bicuspids  and  molars.  The  deep  portions  of 
such  cavities  should  be  thoroughly  disinfected. 


FORMATION  OF  CAVITIES  FOR  FILLING. 

As  a  rule,  remove  all  frail  and  overhanging  walls.  Some- 
times when  it  is  desirable  to  save  them,  as  in  presenting  sur- 
faces, they  may  be  strengthened  by  lining  with  cement. 
Remove  all  unsupported  enamel  from  the  cervical  wall.  This 
wall  .should  be  at  right  angles  to  the  surface  of  the  tooth. 


FORMATION    OK    CAVITIES    TOR    FILLIN(;.  6l 

Make  the  lateral  walls  of  cavities  in  incisors  and  cuspids  of 
such  form  as  they  will  most  conveniently  take,  and  make  a 
well-defined  undercut  at  the  cervical  wall,  and  also  at  the  part 
next  the  cuttin<^  edge,  to  retain  the  filling. 

The  lateral  walls  of  proximal  cavities  in  bicuspids  and 
molars  should  generally  be  undercut  or  grooved,  and  if  the 
grinding  surface  is  not  cut  through,  this  also  should  be  slightly 
undercut.  If  this  surface  is  cut  through,  the  grooves  of  the 
lateral  walls  may  extend  through  the  opening,  thus  presenting 
a  dovetailed  outline  (Fig.  65),  or  the  opening  maybe  left  as  in 
Fig.  66.  For  making  these  grooves  use  a  small  bur,  hoe  or 
chisel. 

If  the  cavity  is  of  considerable  size,  the  lateral  walls  should 
be  cut  away,  as  shown  in  Fig.  67,  so  that  when  filled,  the  filling 

Fig.  65.  Fig.  66.  Fig.  67. 


only  will  come  in  contact  with  the  adjoining  tooth,  leaving  the 
margins  free. 

Let  all  angles  be  rounded  and  smooth.  For  filling  with 
cohesive  gold,  retaining  pits  are  usually  made  in  which  to  start 
the  filling.  Use  a  small,  flat,  square-pointed  drill,  and  drill  the 
holes  in  the  dentine  near  the  enamel,  and  generally  parallel 
with  the  long  axis  of  the  tooth.  Avoid  drilling  toward  the 
pulp.  A  depth  equal  to  the  diameter  of  the  drill  is  sufficient. 
Retaining  pits  are  condemned  by  many  as  unnecessary  and  a 
source  of  danger  to  the  pulp.  In  bicuspids  one  retaining  pit 
is  usually  sufficient,  and  is  better  made  at  the  middle  jiortion 
of  the  cervical  wall,  as  the  dentine  is  thickest  at  this  point. 
These  are  not  needed  for  non-cohesive  gold  or  for  plastic 
fillines. 


62  OPERATIVE    DENTISTRY. 

In  grinding  surfaces  the  walls  of  the  cavity  should  be  nearly- 
parallel,  with  slight  undercuts  at  opposite  points.  The  same 
rules  apply  to  the  formation  of  cavities  on  buccal,  palatal  or 
lingual  surfaces.  For  the  formation  of  these  cavities  various 
forms  and  sizes  of  burs  are  best  suited,  but  the  work  may  be 
well  done  with  excavators  and  chisels. 


EXCLUSION   OF   MOISTURE. 

To  obtain  the  best  results,  the  cavity  must  be  kept  dry 
during  the  operation  of  filling.  For  this  purpose  use  napkins, 
bibulous  paper,  the  saliva-pump  or  rubber  dam.  Napkins 
from  three  to  six  inches  square,  folded  into  a  small  compass 
and  held  over  the  openings  of  the  ducts  of  the  salivary  glands, 
and  each  side  of  the  tooth  to  be  operated  upon,  will  exclude 
all  moisture  long  enough  for  an  ordinary  operation,  and  if  a 
saliva-pump  be  also  used  the  cavity  may  be  kept  dry  for  an  in- 
definite time  by  an  occasional  change  of  the  napkins.  Snow's 
saliva-pump  is  effective,  but  where  water  pressure  can  be  ob- 
tained, the  saliva  ejector  is  the  most  desirable  and  efficient. 

The  rubber  dam  properly  adjusted  is  the  most  perfect  means 
for  the  exclusion  of  moisture.  Take  a  piece  of  strong  rubber 
dam  of  medium  thickness,  about  seven  inches  square,  and  for 
application  to  the  upper  teeth  punch  some  holes  about  one 
and  a  half  inches  from  the  edge  and  one-eighth  to  one-fourth 
of  an  inch  apart,  generally  on  a  line  parallel  with  the  edge  of 
the  rubber. 

For  lower  teeth  punch  the  holes  toward  the  lower  part  of 
the  rubber,  and  not  less  than  two  inches  from  either  edge. 

The  rubber  may  be  placed  upon  the  face,  and  the  points  for 
the  holes  indicated  by  marking  over  the  tooth  or  teeth  when 
the  rubber  is  carried  to  place. 

The  rubber  should  be  supported  upon  the  face  with  the 
holder  before  stretching  it  over  the  teeth,  as  thus  the  edges  are 
prevented  from  folding  over  and  interfering  with  the  applica- 
tion of  the  rubber  and  the  ligature  or  clamp. 


EXCLUSION    OF    MOISTUKK. 


63 


For  cavities  in  the  cutting  edges  or  grinding  surface  fre- 
quently only  one  tooth  will  need  to  be  exposed,  but  if  proxi- 
mal fillings  are  to  be  made,  two  teeth  at  least  must  be  exposed. 
To  suj)port  the  rubber  dam  upon  the  face,  use  a  rubber  dam 
holder — one  made  from  a  pair  of  ordinary  sleeve  catches 
connected  by  elastic  braid  is  convenient  and  effective.  (Fig. 
68.)  A  good  form,  also,  is  Cogswell's  holder,  shown  in  Fig. 
69,  also  Perry's,  Fig.  70. 

Before  applying  the  rubber,  prove  by  passing  silk  between 
the  teeth,  that  there  are  no  sharp  edges  to  interfere  with  its 


Fig.  68. 


passage.  For  this  purpose  and  for  ligatures,  floss  silk,  not 
too  coarse,  well  waxed,  is  best.  Binding-wire  makes  an  excel- 
lent ligature  in  many  instances,  especially  when  the  cavity  is 
at  or  below  the  margin  of  the  gum. 

Fasten  the  dam-holder  to  each  upper  corner  of  the  rubber, 
carry  the  elastic  around  the  head  and  tighten  it,  bringing  the 
upper  edge  of  the  rubber  across  the  upper  lip  (Fig.  71),  then 
with  the  forefinger  of  each  hand  stretch  the  rubber  over  the 
teeth.  If  the  teeth  are  too  close  together  for  the  rubber  to 
pass  easily,  apply  a  little  soap,  and  it  may  then  be  readily  car- 
ried up  with   the   ligature.     The  ligature   should    be  passed 


64 


OPERATIVE    DENTISTRY. 


twice  around  the  tooth  and  drawn  only  closely  enough  to  turn 
the  edges  of  the  rubber  upward  on  the  neck  of  the  tooth,  thus 
avoiding  pain  as  much  as  possible,  tying  firmly  with  a  square 
or  a  surgeon's  knot. 

Should  the  ligature  be  impracticable  or  inconvenient,  apply, 


Fig.  69. 


with    the    clamp   forceps,  one  of  the  numerous  rubber-dam 
clamps. 

To  confine  the  lower  portion  of  the  rubber,  attach  a  second 
dam-holder  to  the  lower  corners,  allowing  the  band  to  pass 


EXCLUSION    OF    MOISTURE. 


65 


around  the  back  of  the  neck,  as  in  Fil,^  72.     Weights  are  also 
used  for  this  purpose. 

Having  the  rubber  dam  thus  adjusted,  place  in  ])osition  the 
mouth-piece  of  the  saUva-pump,  and  the  work  will  be  kept  dry 
and  the  patient  comfortable. 

Fig.  70. 


In  some  cases  the  clamp  may  be  applied  to  the  tooth  first 
and  the  rubber  stretched  over  it  and  the  silk  applied.  This 
may  be  readily  done  if  the  hole  in  the  rubber  is  made  a  little 
larger  than  usual. 


66 


OPERATIVE    DENTISTRY. 


An  assistant,  if  at  hand,  may,  with  an  instrument,  hold 
the  rubber  down  on  the  neck  of  the  tooth  while  the  silk  is 
applied. 

When  the  silk  is  to  be  applied  far  back  in  the  mouth,  it 


Fig.  71 


//j/h 


■r^ij ^^   ^Adjustment  of  rubter'dam 

//'///>!/ /r,/iu-  to  upper  teeLli, 

'  ^'^   JJ/'  plfl'ii 


^""mm„pnf^ 


EXCLUSION    OF    MOISTURE. 


67 


may  be  wound  around  the  little  fin<^er  of  each  hand  and  with 
the  forefingers  carried  back  and  pressed  down  between  the 
teeth. 

Fig.  72. 


Adjustment    of    rubber  dam  to  under  teetk. 


68  OPERATIVE    DENTISTRY. 

GOLD  FOR  FILLING. 

Gold  is  the  most  elegant  material  for  filling  teeth  that  we 
possess,  and  for  most  cases  it  is  the  best.  Though  not  the 
color  of  the  tooth,  it  receives  and  retains  so  fine  a  polish  that 
it  is  less  objectionable  than  any  other  material. 

Gold  is  prepared  in  two  forms — foil  and  crystal  or  sponge 
gold.  Foil  is  used  cohesive  and  non-cohesive.  Non-cohe- 
sive foil  is  so  prepared  that  it  will  not  cohere  when  the 
surfaces  are  brought  in  contact.  Cohesive  foil  is  prepared  by 
annealing  so  that  the  particles  will  cohere  when  the  surfaces 
are  brought  in  contact,  and  it  may  thus  be  welded  into  a  solid 
mass  while  cold.  For  instance,  two  sheets  of  foil,  well  annealed, 
laid  together  and  pressed  by  passing  over  them  a  paper-folder, 
become  united  as  one  sheet. 

Most  of  the  non-cohesive  foil  now  made  may  be  rendered 
cohesive  by  annealing. 

A  sheet  of  gold  foil  is  four  inches  square.  It  is  numbered 
according  to  its  weight,  a  sheet  of  No.  3  weighing  three  grains  ; 
of  No.  4,  four  grains,  etc.  A  book  is  one- eighth  of  an  ounce. 
Foil  is  used  of  various  thicknesses,  from  No.  2  to  No.  120,  or 
thicker.  Gold  in  Nos.  20  to  240  is  prepared  by  rolling,  while 
foil  thinner  than  No.  20  is  made  by  beating  the  rolled  gold  to 
the  required  thinness. 

Gold  foil  may  be  prepared  for  use  in  various  forms,  as  the 
rope,  the  tape,  the  mat,  the  compact  and  the  loose  block,  the 
compact  and  the  loose  cylinder,  and  the  ribbon. 

For  use  cohesively,  cut  the  foil  into  strips  of  one-fifth  or 
one-fourth  of  a  sheet,  and  roll  into  ropes  with  a  napkin,  or, 
better,  with  the  Adams  roller,  then  cut  into  pieces  one-fourth 
of  an  inch  or  more  in  length,  according  to  the  convenience  of 
the  operator  and  the  requirements  of  the  case. 

For  rolling  the  foil,  take  a  large  napkin  or  fine  towel  and 
fokl  lengthwise  to  a  width  of  four  or  five  inches,  then  fold  this 
once  upon  itself,  and,  placing  the  strip  of  foil  in  the  fold,  by  a 
dexterous  movement  of  the  upper  portion  of  the  napkin  upon 
the  lower  it  may  be  rolled  into  a  rope. 


GOLD    FOR    FILLING 


69 


The  Adams  Roller  consists  of  two  plates  of  tin,  three  and 
a  half  by  five  inches,  with  the  edges  turned  over  and  a  small 
handle  attached  to  the  outside  of  each  plate  and  a  piece  of 
thick  rubber  dam  of  the  same  size. 

The  edges  of  the  rubber  are  confined  to  the  upper  edge  of 
each  plate  by  folding  the  tin  upon  itself  and  hammering  it 
down  closely  upon  the  rubber.     (Fig.  73.) 

The  rubber  should  first  be  thoroughly  washed,  and  when- 
ever the  gold  has  a  tendency  to  stick  to  it  the  washing  should  , 
be  repeated. 

In  the  use  of  this  the  rubber  is  folded  upon  itself,  the  strip 


of  gold  laid  within  it,  crumpled  a  little  endwise  with  pliers, 
and  then  dexterously  rolled  into  a  rope. 

The  following  excellent  directions  for  preparing  gold  in 
various  other  forms  are  given  by  Dr.  Jack,  in  the  "  American 
System  of  Dentistry  "  : — 

"  The  tape  is  made  by  folding  any  portion  of  a  sheet  over 
and  over  again  until  a  desired  width  and  thickness  is  pro- 
duced. It  is  not,  however,  considered  advantageous  to  have 
the  number  of  folds  in  each  tape  greater  than  eight,  which, 
when  the  gold  is  No.  4,  makes  the  tape  equal  to  No.  32.     If 


70  OPERATIVE    DENTISTRY, 

the  tape  is  to  be  used  in  this  form  by  folding  it  into  the  cavity, 
as  will  be  described  later,  it  should  be  of  non-cohesive  gold, 
since  otherwise  the  adherence  of  the  folds,  as  they  pass  and 
touch  each  other,  becomes  an  impediment  to  consolidation. 
The  tape  is  most  conveniently  formed  by  laying  the  suitable 
portion  of  the  sheet  upon  a  clean  napkin  or  a  piece  of  amadou, 
and  after  placing  the  edge  of  the  gold  spatula  in  the  middle, 
the  napkin  and  spatula  are  laid  over  to  one  side;  this  is  done 
.three  times  successively.  By  this  means  the  gold  is  formed 
into  a  tape  without  the  fingers  having  come  in  contact  with  it, 
which  is  a  point  of  considerable  importance,  since  the  cleanest 
fingers  will  impart  some  soil  to  the  foil." 

"  The  Mat. — If  it  is  desirable  for  any  reason  to  use  small 
portions  of  the  tape,  it  is  cut  transversely  in  small  pieces, 
which  are  called  mats.  These,  when  of  non-cohesive  gold, 
are  of  considerable  use  in  very  small  cavities,  and  are  also  of 
use  in  large  fillings  when  made  of  semi-cohesive  gold.  One 
form  of  tape  is  made  by  a  tool  which  compresses  the  gold  into 
this  shape  ;  if  from  this  kind  of  tape  mats  are  cut,  they  may 
be  used  with  advantage  if  of  very  cohesive  gold.  The  mat  is 
of  most  service  in  proximate  cases  when  there  may  not  be 
sufficient  room  to  introduce  larger  and  thicker  pieces  of  gold. 
These  can  be  inserted  edgewise  between  the  teeth,  and  after- 
ward be  carried  into  place  and  consolidated  according  to 
the  method  of  packing  employed  at  the  time.  The  mats  of 
non-cohesive  gold  are  frequently  of  service  in  filling  the 
smaller  sulci,  particularly  of  bicuspids.  In  introducing  cohe- 
sive-gold mats,  the  best  results  are  produced  by  making  thin 
layers  of  gold,  since  the  force  employed  is  more  effective  in 
producing  thorough  consolidation.  If  thick  masses,  like  pel- 
lets, arc  employed,  much  of  the  force  is  distributed  in  over- 
coming the  impediment  presented  by  the  corrugations. 

"The  Block. — The  compact  block  is  formed  by  folding  a 
tape  on  itself  a  number  of  times,  which  is  done  by  seizing  it  in 
the  pliers  and  making  turns  of  any  desired  size,  either  square 
or  narrow.     This  form  should  be  composed  of  non-cohesive 


GOLD    FOR    FILLING.  J  \ 

gold,  as  Otherwise  a  mass  of  so  compact  a  nature  would  become 
unmanageable  by  the  cohesion  of  the  layers.  These  blocks 
are  useful  in  commencing  large  proximate  cavities,  they  being 
used  upon  the  cervical  wall.  Their  form,  the  parallel  direc 
tions  of  their  layers,  the  plastic  nature  of  the  arrangements  of 
the  layers,  and  the  softness  of  the  gold  comprising  them,  enable 
this  part  of  the  filling  to  be  easily  started.  They  are  also 
excellently  adapted  to  simple  crown  cavities  where  it  is  not 
difficult  to  effect  their  placement.  This  form  of  block  has 
sometimes  been  erroneously  styled  a  cylinder. 

"The  Loose  Block  is  composed  of  cohesive  gold,  and  is  gen- 
erally made  of  what  is  called  corrugated  gold,  the  purpose  of 
the  employment  of  the  latter  being  to  prevent  the  layers  from 
touching  at  more  than  a  few  points.  This  form  of  block  is 
made  by  laying  sheet  upon  sheet  until  a  number  of  layers  are 
so  placed,  when  the  mass  is  cut  into  squares  with  a  razor-like 
instrument.  These  blocks  are  useful  only  in  building  up  gold 
upon  a  previously-established  foundation  of  cohesive  gold. 

"The  Compact  Cylinder. — This  form  is  made  by  rolling  a 
tape  of  non-cohesive  gold  on  a  fine  brooch,  commencing  at  one 
end  of  the  tape  and  continuing  the  movement  until  the  desired 
size  is  reached,  by  which  means  the  cylinders  may  be  made 
very  compact. 

"The  Loose  Cylinder  bears  some  external  resemblance  to 
the  previous  kind,  but  is  in  all  other  respects  very  different. 
Cylinders  of  this  form  can  be  made  only  by  manufacturers. 
They  are  composed  of  several  sheets  laid  one  upon  the  other, 
and  are  then  wrapped  loosely  upon  a  needle-like  piece  of  steel. 
When  the  brooch  is  removed,  they  are  cut  into  definite  lengths 
by  a  sharp  tool,  and  are  di.stributed  in  assorted  sizes.  They 
are  usually  made  of  corrugated,  cohesive  or  semi-cohesive  gold, 
and  they  complement  the  loose  block. 

"  They  are  employed  in  the  commencement  of  fillings,  for 
which  purpose  they  are  not  usually  annealed,  and  are  recom- 
mended on  account  of  the  facility  with  which  they  can 
be  packed.     There  is,  however,  considerable  loss  of  force  in 


72 


OPERATIVE    DENTISTRY. 


overcoming  the  corrugations  of  the  foil  of  which  they  are 
composed.  Still,  there  is  no  question  that  there  are  certain 
advantages  possessed  by  these  cylinders,  as,  when  they  are 
fixed  at  one  end  there  is  less  danger  of  displacing  this  fixed 
portion  when  force  is  applied  to  the  other  end,  for  the  reason 
that  the  corrugations  permit  some  movement  to  take  place 
in  the  unconsolidated  part  without  disturbing  the  part  first 
secured.  Probably  on  account  of  the  impediment  offered  by 
the  corrugations,  they  are  not  well  adapted  to  building  out  in 


Fig.  74. 


contour   operations,   and   other   forms   should   be   substituted 
when  this  portion  of  the  operation  is  reached. 

"The  Ribbon  is  formed  of  whole  sheets,  and,  in  some  cases, 
of  two  sheets  of  fiat  cohesive  foil,  folded  like  a  tape,  three 
times,  which  produces  No.  32  when  one  sheet  is  taken.  The 
folding  should  be  loosely  done.  These  ribbons  are  shown  at 
Fig.  74.  The  ribbons  are  taken  up  with  delicate  foil-pliers 
and  cut  across   into   little  strips,  represented  at  d  and  c,  care 


GOLD    FOR    TILLING.  73 

being  taken  to  protect  them  from  injury,  the  width  of  these 
strips  being  varied  with  the  size  of  the  case.  Each  of  the 
strips  is  afterward  taken  up  by  pliers  and  heated  to  redness  at 
the  moment  of  using.  It  was  with  this  form  of  gold  that  the 
beautifully-executed  operations  of  Dr.  Webb  were  generally 
performed. 

"This  form  of  gold  is  properly  adapted  only  for  building  out 
teeth  beyond  the  confines  of  the  cavity,  and  for  entirely  filling 
such  cases  as  depend  for  their  support  and  retention  upon  a 
few  retaining  points  or  imperfect  grooves  yvhich  have  been 
formed  in  weak  margins.  It  is  also  the  form  of  gold  best 
adapted  to  the  use  of  the  electro-magnetic  mallet,  for  the 
reason  that,  as  that  instrument  is  efficient  only  through  insen- 
sible distances,  it  is  important  not  to  have  much  bulk  of  gold 
beneath  its  points, 

"  Rolled  Gold. — Several  thicknesses  of  heavy  gold  have  been 
recommended,  in  some  instances  as  high  as  No.  160  having 
been  used.  Reasonable  practice  in  this  respect  has  settled 
that  Nos.  20  to  30  are  the  proper  limits  of  heavy  foil.  Pure 
gold,  prepared  by  rolling,  has  a  remarkable  degree  of  softness 
and  toughness,  and  when  made  cohesive,  manifests  this  quality 
in  a  higher  degree  than  the  same  gold  would  if  beaten  into 
foil.  When  made  of  cohesive  gold,  and  this  property  fully 
developed  by  heat,  the  adhesion  is  exceedingly  tenacious, 
which  adapts  the  gold  for  building  out  cases,  and  for  surface 
fillings  when  it  is  important  to  produce  a  homogeneous  ap- 
pearance of  the  surface.  When  made  of  non-cohesive  gold, 
narrow  strips  may  be  inserted  along  the  margins  of  stoppings 
packed  by  hand  pressure,  and  they  may  also  be  used  for 
filling  the  pulp-canals.  In  this  form  it  is  not  difficult  to  jiack  it 
into  fine  roots,  and  in  this  situation  it  will  also  well  bear 
malleting." 

The  methods  of  packing  non-cohesive  and  cohesive  gold 
are  essentially  different.  Non-cohesive  gold  should  be  packed 
wholly  by  the  wedging  process, 

Pluggers  for  packin<T  non-cohesive  gold  should  be  smooth 


74  OPERATIVE    DENTISTRY. 

and  wedge-shaped ;  those  for  condensing  the  filHng  after  its 
introduction  should  have  serrated  points.  They  should  be  of 
various  forms  and  sizes  to  suit  the  requirements  of  different 
cases.  As  most  of  these  instruments  are  for  use  with  hand 
pressure,  the  handles  should  be  of  suitable  size  and  form  to  be 
firmly  grasped  by  the  hand,  but  the  condensing  instruments 
may  be  for  use  with  the  mallet. 

The  portions  of  gold  of  whatever  form,  whether  blocks, 
cylinders,  mats  or  tape,  should  be  arranged  generally  in  parallel 
layers,  and  they  should  be  of  sufficient  length  to  extend  from 
the  bottom  to  a  little  beyond  the  margin  of  the  cavity.  Excep- 
tions to  this  may  be  made  in  undercuts  or  depressions  in  the 
cavity  or  in  the  filling.  A  sufficient  number  of  pieces  are 
placed  in  the  cavity  to  loosely  fill  it,  a  wedge-shaped  plugger 
is  passed  into  the  filling  and  the  gold  pressed  toward  the  sides 
of  the  cavity,  and  additional  portions  of  gold  should  be  added 
as  at  first,  and  the  wedging  process  repeated.  Continue  this  with 
smaller  pluggers  and  smaller  pieces  until  the  cavity  is  full.  Test 
every  portion  of  the  surface  of  the  filHng,  and  whenever  a  soft 
spot  is  found  repeat  the  former  process. 

After  the  plugger  is  inserted,  tipping  it  in  several  directions 
toward  the  edges  of  the  cavity  will  increase  its  efficiency  and 
more  thoroughly  pack  the  gold. 

When  the  cavity  is  completely  filled,  the  protruding  gold 
should  be  condensed  with  a  large,  serrated  plugger,  followed 
by  instruments  of  smaller  size  until  the  entire  surface  is  tho- 
roughly condensed. 

Grind  or  file  down  the  inequalities  of  the  surface,  burnish 
and  then  polish. 

Cohesive  gold  maybe  packed  by  hand  pressure  or  by  mallet 
force.  The  packing  surfaces  of  the  pluggers,  in  either  case, 
should  be  finely  serrated  and  considerably  broad,  that  they  may 
carry  the  gold  before  them  and  not  penetrate  it. 

Points  for  hand  pressure  may  have  great  variety  of  form. 
The  packing  surface  should  be  ovoid  in  form  and  it  may 
present  in   any  desired   direction,  but  the  surfaces  of  mallet 


GOLD    FOR    FILLING.  75 

pluggers  must  present,  in  the  main,  in  a  line  with  the  axis  of  the 

instrument,  as  all  the  force  is  applied  in  this  direction.  Sizes 
and  forms  are  shown  in  chapter  on  Instruments. 

A  filling  may  be  started  in  retaining  pits  or  by  placing  in  the 
bottom  of  the  cavity  pieces  of  crystal  gold  in  sufficient  quantity 
to  extend  across  the  cavity  and  be  held  in  position  by  the 
opposing  walls ;  or  blocks,  or  cylinders  of  foil,  slightly  annealed, 
may  be  used  instead  of  the  crystal  gold. 

To  continue  the  filling  with  ropes  of  foil  prepared  as 
previously  described,  a  piece  of  convenient  length  is  taken 
by  the  end  in  the  pliers,  passed  over  the  flame  of  the 
lamp,  and  the  end  touched  to  the  gold  in  the  cavity,  to  which 
it  coheres.  With  the  pluggcr  this  is  condensed,  being  folded 
upon  itself  or  carried  to  other  parts  of  the  cavity.  This  is 
repeated  till  the  cavity  is  full.  Theplugger  is  placed  upon  the 
gold,  pressure  exerted,  and  at  the  same  time  the  plugger  is 
rolled  a  little  upon  the  gold,  thus  bringing  all  parts  to  bear. 

While,  theoretically,  the  crimps  formed  in  the  gold  by  roll- 
ing it  into  the  ropes  tend  to  hinder  consolidation,  yet  when 
used  in  so  attenuated  a  form  as  one-fifth  of  a  sheet  rolled 
loosely,  it  practically  amounts  to  nothing,  as  so  small  a  portion 
of  gold  comes  under  the  plugger  at  any  one  time.  The  rope 
seems  the  better  form  because  it  is  ready  to  be  folded  in  any 
direction  and  lie  in  any  part  of  the  cavity.  It  may  be  used  in 
convenient  lengths,  from  one-fourth  of  an  inch  to  four  inches. 

From  two  to  six  pounds  pressure  will  be  found  sufficient  to 
thoroughly  consolidate  the  gold.  A  filling  carefully  packed  in 
this  manner  will  be  found  so  solid  as  scarcely  to  yield  to 
mallet  force.  Cylinders  and  blocks  of  considerable  thickness 
may  be  perfectly  condensed  in  this  manner.  Tape  or  ribbons 
may  also  be  used  in  the  manner  described  above. 

Crystal  Gold. — The  best  preparation  of  this  form  of  gold 
is  produced  by  electrolysis.  It  is  prepared  in  different  degrees 
of  density,  and  is  known  as  Nos.  i,  2  and  3,  No.  i  being  the 
softest. 

This   gold  is  specially   useful    in    starting   fillings    without 


76  OPERATIVE    DENTISTRY. 

retaining  pits,  as   it  is  free   from  any  tendency  to  curl  or  roll 
when  condensed. 

It  is  less  reliable  for  margins  than  foil,  but  if  skillfully 
manipulated,  added  in  thin  layers,  and  each  layer  thoroughly 
condensed,  fillings  may  be  made  which  cannot  be  excelled  by 
any  other  form  of  gold. 

Annealing  Gold. — The  first  annealing  of  gold  foil  after 
being  beaten  develops  its  cohesive  quality  by  causing  a 
change  in  the  molecular  structure.  Quite  a  high  degree  of 
heat  is  necessary  for  this  purpose.  Subsequent  exposure 
renders  the  foil  non-cohesive,  owing  to  a  condensation  of 
gases  or  moisture  from  the  air  upon  the  surface.  To  restore 
the  cohesive  quality,  a  degree  of  heat  sufficient  to  drive  off 
these  gases  is  needed,  but  this  is  far  short  of  redness. 

It  is  generally  best  to  prepare  the  gold  in  the  form  and  size 
required,  and  then  anneal  as  it  is  used. 

The  annealing  may  be  done  by  holding  the  gold  over,  or 
passing  it  through,  the  alcohol  flame,  or  on  a  plate  of  mica  or 
platinum  over  the  alcohol  flame  or  Bunsen  burner. 

The  larger  forms  of  gold,  as  cylinders  and  blocks,  are  best 
annealed  by  the  latter  method. 

When  gold  is  taken  in  the  pliers  for  annealing,  it  should  be 
seized  by  as  minute  a  portion  as  possible,  as  the  pliers  con- 
dense the  portion  included  and  prevent  its  being  properly 
heated. 

THE  DENTAL  MATRIX. 

The  matrix,  as  used  in  dental  operations,  consists  of  a 
plate  or  band  of  metal  so  applied  to  a  tooth  as  to  supply 
a  missing  wall,  and  thus  convert  a  compound  cavity  into  a 
simple  one. 

Matrices  formerly  used  were  so  made  as  to  require  support 
from  an  adjoining  tooth.  Those  recently  invented,  which  con- 
sist of  a  band  embracing  the  tooth  operated  on,  render  other 
support  unnecessary  and  are  superseding  the  use  of  the  former. 
The  following  are  some  of  the  recent  forms : — 


THE    DENTAL    MATKIX. 
Fig.  75. 


77 


C  D 


Fig.  75    represents  Guilford's  band  matrix,  which  has  the 
merit  of  passing  into  but  one  interdental  space. 


Fig.  76. 


78 


OPERATIVE    DENTISTRY. 


Figs.  76  and  'jj  show  Brophy's  band  matrix.  On  the  lower 
teeth  it  is  better  to  place  the  screw  on  the  lingual  surface. 
They  are  in  several  sizes. 

Herbst  invented  a  matrix  of  ready  application  to  any  case. 
It  is  made  by  bending  a  piece  of  thin  German  silver  or  steel 
around  the  tooth  and  pinching  it  up  with  pliers,  then  removing 
from  the  tooth  and  soldering  with  soft  solder.  A  little  solu- 
tion of  zinc  chloride  for  flux,  and  a  bit  of  soft  solder  are 
applied  and  held  in  the  flame  of  an  alcohol  lamp,  and  the 
solder  quickly  flows. 

Fig.  yZ  represents  the  Ladmore-Brunton  matrix  and  flex- 
ible key.     It  is  a  convenient  and  efficient  device. 


Fig.  78, 


A  good  matrix  may  be  made  by  striking  thin  metal  from 
dies  formed  from  the  proximal  surfaces  of  the  teeth,  and  held 
in  position  by  ligatures  around  the  teeth.  Projections  may  be 
left  near  the  cervical  edge  to  prevent  the  ligature  from  slipping 
against  the  gum,  and  some  portion  of  the  edge  may  be  bent 


USE    OF    THE    MALLET. 


79 


over  the  grinding  surface  to  prevent  the  matrix  from  slipi)ing 
too  far  down. 

Dr.  Jack's  matrices   were  the  first  formed  specially  for  the 
purpose,  and  are  shown  in  Fig.  79. 


Fig.  79. 


They  are  formed  with  a  depression  corresponding  to  the 
desired  form  of  the  filling,  and  are  held  in  position  by  wedges 
against  the  adjoining  teeth. 

When  a  matrix  is  used  in  filling,  great  care  should  be  taken 
to  pack  the  gold  thoroughly  against  the  edges  of  the  cavity 
and  against  the  matrix,  else  these  portions  of  the  filling  will  be 
found  imperfect  when  the  matrix  is  removed. 


USE   OF   THE   MALLET. 

In  applying  mallet  force  in  the  packing  of  gold  the  plugger 
point  is  placed  upon  the  gold  and  a  blow  is  struck  upon  the 
end  of  the  handle. 


80  OPERATIVE    DENTISTRY. 

The  mallet  force  is  wholly  in  a  line  with  the  axis  of  the  in- 
strument, hence  the  packing  surface  of  the  plugger  should  be 
as  nearly  as  possible  at  right  angles  to  the  axis  of  the  handle. 
If  pluggers  with  surfaces  oblique  to  the  axis  are  used,  strong 
lateral  pressure  should  be  made  when  the  blow  is  struck,  so 
that  the  resultant  force  will  be  in  a  line  with  the  face  of  the 
plugger.     (Fig.  80.) 

Better  results  are  obtained  if  the  face  of  the  plugger  is  quite 
broad  and  a  little  oval.  The  serrations  should  be  very  fine 
and  shallow. 

The  blow  may  be  struck  with  the  hand  mallet,  the  spring 
mallet,  the  engine,  the  pneumatic  or  the  electric  mallet. 

The  hand  mallet  may  be  used  by  the  operator  himself,  hold- 
ing the  plugger  in  one  hand  and  striking  the  blow  with  the 


Fig.  80. 


The  line  a  b  represents  the  direction  of  the  mallet  force,  a  d  the  lateral  pressure,  and  a  c  the 

resultant  force. 


other,  or  the  mallet  may  be  used  by  an  assistant.  All  the 
machine  mallets  are  used  by  the  operator. 

The  blow  should  be  rather  light,  but  sharp  and  quick,  that 
the  force  may  be  expended  upon  the  surface  of  the  filling, 
as  a  slow,  heavy  blow  tends  to  carry  the  force  to  a  greater 
depth  and  to  spread  the  mass  of  the  filling,  and  thus  injure 
the  tooth. 

A  considerable  thickness  of  gold  should  be  placed  at  the 
margins  of  the  cavity  before  the  plugger  is  used,  so  that  the 
blow  may  not  injure  the  enamel. 

Much  malleting  should  be  avoided,  as  more  than  enough  to 
condense  the  gold  only  tends  to  harden  it,  thus  making  it  less 
cohesive,  brittle  and  disposed  tg  draw  away  from  the  sides  of 
the  cavity. 


USE    OF    TIIK    MALLET.  51 

All  the  forms  of  gold  pre\'iou.sl\'  mentioned  may  be  con- 
densed b)'  the  use  of  the  mallet. 

Generally,  one  blow  in  each  position  of  the  plu^<^er  is  suffi- 
cient, but  if  large  pieces  of  gold  are  used,  or  if  the  blows  are 
very  light,  two  or  more  may  be  of  advantage. 

One  method  is  to  exert  considerable  hand  pressure  upon  the 
plugger  when  the  blow  is  dcli\crecl ;  another  is  to  simply  hold 
the  plugger  upon  the  gold,  and  depend  wholly  upon  the  blow 
to  condense  it ;  and  a  third,  used  in  the  later  stages  of  the 
filling,  is  to  hold  the  plugger  in  almost  immediate  contact  with 
the  gold,  the  blows  being  light  and  delivered  very  rapidly, 
constantly  changing  the  position  of  the  instrument  over  the 
gold  as  the  electric  mallet  is  used. 

The  automatic  mallet,  in  which  the  blow  is  struck  by  the 
expansion  of  a  spiral  spring,  is  in  more  general  use  than  any 
other,  and  best  serves  the  purpose  of  the  average  operator. 
The  blow  may  be  accurately  regulated,  from  the  lightest  tap 
to  one  as  heavy  as  is  ever  required. 

With  the  engine  mallet  the  blow  is  struck  by  the  action  of 
a  cam  on  a  pulley  driven  by  the  engine,  which,  as  it  revolves, 
strikes  upon  the  end  of  the  plugger,  and  thus  impacts  the 
gold.  It  strikes  from  fifteen  to  twenty  blows  per  minute,  and 
should  be  held  in  the  fingers  as  a  pen  is  held  in  writing,  and 
thus  freely  moved  about  at  such  a  distance  from  the  surface  of 
the  filling  that  when  the  point  is  projected  by  the  blow  it  will 
impinge  upon  the  gold  with  sufficient  force  to  condense  it. 

The  electric  mallet  is  a  desirable  instrument,  and  is  preferred 
by  many  operators.  As  the  action  is  exceedingly  quick,  the 
blow  has  eminently  the  quality  of  velocity.  "  It  is  for  this 
reason  that  the  blow  of  the  light  armature  of  this  instrument 
is  so  powerful.  The  impaction  of  gold  b)'  it  exceeds  in  solidity 
that  produced  by  an}'  other  means.  If  the  faces  of  the  instru- 
ments are  fine  or  nearly  smooth,  the  state  of  the  gold,  if 
cohesive,  is  one  of  absolute  solidity.  The  point  of  the  instru- 
ment is  driven  forward  the  merest  fractional  distance ;  hence 
it  can  be  used  for  packing  gold  against  the  frailest  walls. 


Sz 


OPERATIVE    DENTISTRY. 


"  The  instrument  is  held  in  the  hands  as  it  appears  in  Fig. 
8i,  and  is  handled  with  a  touch  which  is  difficult  in  lancruaee 
to  describe.  The  point  is  not  applied  to  the  gold  with  some 
pressure,  as  other  instruments  are,  but  is  simply  touched 
to  the  surface  of  the  mass,  and  in  this  free  state  is  rapidly 
skimmed  over  the  gold,  the  ear  all  the  while  being  guided 
by  the  sound  of  the  plugger  on  the  gold,  which,  among  the 
other  noises  of  the  instrument,  is  clearly  observable  by  the 
expert  operator. 

Fig.  8i. 


"  When  sensible  pressure  is  employed  the  action  of  the  in- 
strument becomes  excessively  disagreeable  and  cannot  long  be 
tolerated;  but  when  the  touch  of  the  operator  is  delicate,  long 
operations  are  endured  without  notable  irritation.  The  deli- 
cacy of  manipulation  indicated  by  the  above  language  will 
necessarily  limit  the  use  of  the  instrument  to  comparatively 
few  persons.     The  facility  of  its  use  can  be  acquired  only  by 


USE    or    THK    MALLET.  (S3 

personal  contact  with  those  skillful  in  its  handling.  It  is  an 
essential  precaution  that  under  no  circumstances  should  the 
point  of  the  instrument  come  into  contact  with  the  margins  of 
the  cavity,  but  should  always  be  so  handled  as  to  be  preceded 
by  the  presence  of  a  layer  of  gold.  For  the  reason  just  given, 
no  description  of  the  particular  manner  of  impacting  gold  with 
it  is  made. 

"The  field  requiring  the  employment  of  this  mallet  and  the 
cultivation  of  facility  with  it  is  in  the  large  contours  and  the 
necessarily  exposed  fillings  of  front  teeth,  which  demand  that 
degree  of  solidity  which  enables  the  most  perfect  finish  to  be 
given  to  them.  This  instrument  is  well  adapted  to  teeth  of 
soft  texture  and  of  frail  character,  for  the  reason  that  the  blows 
of  the  instrument  are  superficial  in  their  effect;  hence,  there  is 
no  danger  of  the  borders  being  injured  by  the  application  of 
its  force,  as  may  be  the  case  when  heavy  hand-force  is  em- 
ployed, or  disintegrated,  as  when  other  mallets  are  used. 

"  The  management  of  the  galvanic  batteries  connected  with 
the  instrument  has  been  considered  an  obstacle,  but  it  is  one 
which  has  no  force  with  a  properly  educated  dentist,  who 
should  be  familiar  with  all  the  chemical  principles  involved. 
Having  this  knowledge,  there  are  no  impediments  to  be 
encountered."* 

The  several  forms  of  gold  and  the  several  methods  of  con- 
densing may  often  be  combined  to  advantage  in  the  filling  of 
a  single  cavity.  It  saves  time  and  is  restful  to  the  operator, 
and  these  are  important  points  in  long  operations. 

The  filling  may  be  well  begun  with  blocks  or  cylinders  of 
semi-cohesive  gold  packed  either  by  hand  pressure  or  with  the 
mallet,  and  to  this  may  be  attached  any  of  the  preparations  of 
cohesive  gold  packed  by  any  method  preferred,  and,  if  readily 
accessible  the  filling  may  be  finished  with  ribbons  and  the 
electric  mallet. 

A  plan  practiced  by  many,  especially  in  proximal  fillings,  is 

*  Dr.  Jack,  in  "  American  System  of  Dentistry." 


84  OPERATIVE    DENTISTRY. 

to  pack  at  the  cervical  wall  a  layer  of  non-cohesive  gold;  this 
is  followed  by  a  layer  of  semi- cohesive  blocks  or  cylinders  ; 
then  from  this  continue  with  cohesive  gold  as  desired. 

Another  plan  is  to  fill  the  margins  and  the  body  of  the 
cavity  with  semi-cohesive  gold,  filling  the  centre  and  finishing 
the  filling  with  cohesive. 


PLASTIC  FILLINGS. 

Amalgam,  Oxychloride  of  Zinc,  Oxyphosphate  of  Zinc, 
and  Gutta-Percha  are  the  plastic  fillings  now  used. 

Amalgmn  is  the  only  plastic  metal  filling.  It  is  compatible 
with  tooth  substance,  consequently  tooth-saving ;  it  has  com- 
paratively low  conducting  power,  hence  it  is  less  likely  than 
gold  to  produce  inflamimation  of  the  pulp ;  it  is  easily  intro- 
duced into  the  cavity,  hence  it  is  applicable  in  places  difficult 
of  access  and  in  cavities  with  frail  walls.  It  is  thought  by  some, 
however,  to  exert  a  deleterious  effect  upon  frail  enamel  walls. 
Its  color  is  objectionable,  and  it  is  inclined  to  assume  the 
spherical  form  and  consequently  to  draw  away  from  the  walls 
of  the  cavity.  Careful  preparation  and  thorough  packing  will 
greatly  modify,  if  not  entirely  overcome,  the  shrinkage  and  the 
tendency  to  assume  the  spherical  form,  and  will  add  greatly  to 
its  preserving  qualities,  and  nice  polishing  and  burnishing  will 
improve  the  color. 

The  best  amalgam  is  fine-grained,  plastic-working,  sets 
quickly,  has  good  edge-strength,  sufficient  hardness  to  resist 
wear  and  density  to  take  a  good  polish. 

Silver,  tin  and  mercury  are  the  essential  constituents  of 
amalgam.  Gold,  copper,  zinc  and  other  metals  are  frequently 
added  in  proportions  varying  from  three  to  seven  per  cent. 

Gold  decreases  the  shrinkage  and  improves  the  color,  and 
copper  is  thought  to  have  a  preservative  effect  on  the  dentine, 
and  to  render  the  filling  less  likely  to  induce  irritation  of 
the  pulp  in  deep  cavities.  Zinc,  not  exceeding  one  and  one- 
half  per  cent,  of  the  alloy,  renders  the  amalgam  more  plastic. 


PLASTIC    FILLINGS.  85 

thus  improving  its  working  qualities.  It  also  improves  the 
color,  and  for  this  object  it  may  be  used  in  larger  quantity, 
even  to  ten  per  cent.,  but  the  plasticity  of  the  amalgam  will 
be  lessened. 

Cadmiu))i  must  not  be  used,  as  it  is  highly  destructive  to  the 
teeth. 

An  amalgam  is  made  of  copper  and  mercury  only,  which  is 
serviceable.  It  becomes  very  dark  in  color,  but  it  saves  the 
teeth  well  and  does  not  stain.     It  neither  shrinks  nor  expands. 

Silver  and  mercury  alone  make  an  amalgam  very  hard, 
dense  and  serviceable,  but  it  turns  very  dark  in  color,  owing  to 
the  sulphide  of  silver. 

Tin  so  modifies  and  improves  the  filling  that  it  has  come  to 
be  esteemed  an  essential  element  of  all  silver  amalgams.  It 
makes  the  alloy  amalgamate  much  more  easily,  makes  the 
filling  finer  grained,  more  plastic,  and  improves  the  color  from 
the  first  and  prevents  its  turning  dark.  It  softens  it,  but  not 
to  its  detriment.  The  proportions  in  which  tin  is  used  range 
from  thirty-five  to  sixty  per  cent,  of  the  alloy. 

To  prepare  an  amalgam  filling,  place  a  sufficient  quantity  of 
the  filings  in  a  small  wedgewood  or  ground  glass  mortar,  or  in 
the  palm  of  the  hand,  add  mercury,  and  rub  them  thoroughly 
together  with  the  pestle  or  with  the  finger ;  add,  if  necessary, 
a  little  more  of  the  filings  to  harden,  or  mercury  to  soften. 
The  paste  should  be  soft  enough  to  cohere  when  pressed,  but 
hard  enough  so  that  mercury  may  not  be  expressed  by  pres- 
sure between  the  thumb  and  finger.  A  little  practice  will 
enable  one  to  judge  correctly.  A  balance  may  be  used  with 
good  results  by  pouring  the  filings  in  one  end  and  the  mercury 
in  the  opposite  cup,  the  balance  showing  the  proper  propor- 
tionate weight  of  each.  The  balance  must  be  adjusted  for  each 
quality  of  alloy. 

Have  the  cavity  dry  and  protected  from  moisture,  insert  the 
filling  in  small  pieces,  placing  it  in  perfect  contact  ^\■ith  all 
parts  of  the  walls  of  the  cavity  by  rubbing  and  gently  tapping 
with  the  plugger,  exercising  the  same  care  as  with  a  gold  filling. 


86  OPERATIVE    DENTISTRY. 

especially  at  the  cervical  wall  and  in  undercuts.  The  tapping 
process  condenses  amalgam  with  remarkable  facility  and 
thoroughness. 

Amalgam  may  be  very  thoroughly  and  satisfactorily  packed 
by  inserting  enough  to  half  fill  the  cavity,  covering  with  a 
layer  or  a  pellet  of  cotton  or  bibulous  paper  and  rotating  the 
burnisher  upon  this  with  pressure,  either  with  the  engine  or 
with  a  hand  burnisher.  Then  add  more  amalgam  and  repeat 
the  burnishing  until  the  cavity  is  filled. 

Remove  surplus  and  burnish  toward  the  edges  until  it  has 
begun  to  set,  then  leave  it,  and  at  a  subsequent  sitting  dress 
down  and  polish. 

If  the  tooth  to  be  filled  is  much  broken  down,  there  may  be 
adjusted  to  the  tooth  a  band  matrix,  cut  to  fit  the  occlusion 
and  filled  and  allowed  to  remain  until  the  amalgam  is  hard, 
when  it  may  be  removed  and  the  filling  finished  as  in  other 
cases. 

Amalgam  was  formerly  washed  in  alcohol  or  solution  of 
bicarbonate  of  soda,  but  at  present  this  is  not  in  favor,  and  it 
is  thought  it  injures  it.     This  is  questionable. 

Copper  amalgam  is  especially  adapted  to  the  filling  of  buccal 
cavities  in  teeth  of  inferior  quality.  It  seems  to  exert  a  pre- 
servative influence.  Its  extreme  hardness  is  an  objection  to  its 
use  in  proximal  cavities,  as  it  is  almost  impossible  to  cut  it, 
if  its  removal  should  from  any  cause  become  necessary. 


GUTTA  PERCHA. 

Giitta  pcrdia  for  filling  is  used  combined  with  oxide  of  zinc, 
and  was  first  known  as  Hill's  stopping,  and  since  by  many 
other  names.  It  is  useful  for  temporary  fillings,  for  root  fill- 
ing, and  for  cavities  with  frail  walls  or  if  near  the  gum.  In 
some  instances  it  lasts  a  long  time,  ten  years  or  more,  but 
when  exposed  to  wear  it  is  soon  destroyed,  and  some  prepa- 
rations of  it  are  softened  by  the  secretions. 

It  is  best  used  by  cutting  in  small  pieces,  laying  them  on  a 


CEMENTS.  87 

warm  slab  of  porcelain  or  tile  until  soft,  and  inserting  one 
piece  at  a  time  until  the  cavity  is  full.  Each  piece  should  be 
warm  enough  to  stick  to  the  walls  or  to  the  portion  already 
inserted,  and  thus  make  a  homogeneous  filling. 

A  coating  of  resin  dissolved  in  ether  applied  to  the  walls  of 
the  cavity  will  cause  the  gutta  pcrcha  to  adhere  firmly.  Chlo- 
rolorm  or  oil  of  cajeput  on  the  burnishers  will  soften  the 
surface  and  aid  in  finishin<i. 


CEMENTS. 

OxycJiloridc  of  zinc  is  useful  for  root  fillings  and  for  partially 
filling  cavities  in  crowns  of  teeth  to  whiten  them.  It  is  the 
lightest  colored  cement  made.  It  is  not  serviceable  for  exposed 
fillings,  though  in  a  few  exceptional  cases  it  has  lasted  seven- 
teen to  twenty  years. 

Mix  the  liquid  and  powder  on  a  palette  to  the  consistency 
of  thick  paste,  and  insert  in  the  cavity.  Wait  for  it  to  harden 
and  finish  at  same  sitting.    For  use  in  root  canals,  see  page  10 1. 

Oxypliosphate  of  zinc  is  phosphoric  acid  and  calcined  oxide 
of  zinc.  This  has  almost  entirely  superseded  the  oxychloride 
of  zinc  for  exposed  fillings,  as  it  is  much  more  durable. 

Mix  with  a  flexible  spatula,  on  a  slab  (a  glazed  tile  four 
inches  square),  the  acid  and  powder  to  the  consistency  of  soft 
putty,  working  in  the  powder  thoroughly,  a  little  at  a  time, 
rubbing  well  with  the  spatula  until  it  works  smooth,  and  con- 
tinuing the  working  until  used,  as  it  begins  to  set  immediately 
on  being  allowed  to  rest.  Insert  quickly  in  convenient  por- 
tions and  insure  perfect  contact  with  the  walls  of  the  cavit}-, 
which  should  be  perfectly  dry.  Dress  off  the  surplus  with 
a  thin  cutting  instrument,  well  oiled,  then  burnish  slightly 
toward  the  edge  with  oiled  burnisher.  Do  not  burnish  hard 
enough  to  move  the  body  of  the  filling  after  it  has  begun  to 
set,  as  it  breaks  up  the  crystallization.  The  filling  should  be 
kept  dry  from  fifteen  to  thirty  minutes.  It  is  well  to  cover  it 
with  gutta  percha  dissolved   in  chloroform  and  allow  it   to 


88  OPERATIVE    DENTISTRY. 

remain  to  protect  from  moisture  until  it  is  fully  hardened. 
When  making  permanent  fillings  it  is  better  to  use  the  rubber 
dam. 

A  good  oxyphosphate  of  zinc  filling  may  be  expected  to  last 
from  one  year  to  five  years. 

The  cervical  wall  may  be  protected  with  gutta-percha  amal- 
gam or  tin  filling  and  the  cavity  then  filled  with  the  cement, 
and  thus  be  made  more  durable. 

For  use  as  temporary  fillings  the  cement  may  be  mixed 
much  thinner  and  used  quickly,  and  not  kept  dry.  Such  fill- 
ings may  be  cut  out  quite  quickly. 

A  temperature  of  about  70°  F.  is  the  most  favorable  for 
mixing  cements. 

COMBINATION   FILLINGS. 

Gold  and  platinum  are  sometimes  used  in  combination,  being 
beaten  together  in  the  manufacture,  the  platinum  between  two 
layers  of  gold.  This  is  manipulated  in  the  same  manner  as 
cohesive  gold.  When  finished  and  burnished  the  platinum 
comes  to  the  surface  and  modifies  the  color  of  the  filling 
according  to  the  amount  of  platinum  in  the  foil,  rendering  it  less 
bright.  The  combination  is  also  much  harder  than  pure  gold, 
a  desirable  quality  for  grinding  surfaces  or  exposed  edges. 

A  combination  of  gold  and  tin  is  made  by  laying  'together 
a  sheet  of  gold  and  of  tin,  each  No.  3,  and  then  rolling  this 
into  ropes  and  preparing  as  directed  for  gold  foil.  This  must 
be  used  as  non-cohesive  foil.  It  is  claimed  that  this  pre- 
serves the  teeth  better  than  gold  ;  it  is  more  easily  packed 
than  gold,  and  is  harder  than  tin. 

Fibrous  foil  is  used  in  combination  with  gold  as  a  founda- 
tion in  large  crown  cavities  or  at  the  cervical  wall  in  proximal 
fillings. 

As  much  of  the  fibrous  foil  is  used  as  seems  desirable,  and 
to  this  the  gold  foil  is  added  and  the  filling  finished. 

Amalgam,  also,  may  be  used  as  a  foundation,  allowing  it  to 
thoroughly  harden  before  adding  the  gold. 


PUKCKLAIN    DISK    FILLINGS.  89 

Recent  experiments  show  that  electric  currents  exist  be- 
tween filhngs  of  tlissiniilar  metals  in  the  mouth,  but  whether 
enough  to  prove  injurious  or  not  is  not  definitely  settled.* 

PORCELAIN    DISK    FILLINGS. 

These  fillings  are  often  preferred  in  cavities  exposed  to  view 
to  avoid  a  show  of  metal.  They  are  disks  of  porcelain  of  a 
size  and  thickness  to  fit  the  cavity  to  be  filled.  They  may  be 
carved  and  baked  specially  for  the  case  or  ground  from  a  tooth 
selected  for  the  purpose.  The  dense  body  of  the  English 
tooth  is  excellent  for  this  purpose,  as  a  surface  which  has 
been  ground  will  take  a  fine  polish. 

Prepare  the  walls  of  the  cavity  to  be  filled  perpendicular  or 
a  little  undercut.  The  outline  may  be  of  any  convenient 
form,  but  there  should  be  no  sharp  angles.  Grind  the  porcelain 
to  the  proper  thickness,  and  get  a  pattern  of  the  outline  of  the 
cavity  as  follows:  Lay  a  piece  of  pattern  tin  over  the  cavity 
and  burnish  around  the  edges  to  mark  the  exact  outline,  being 
careful  to  avoid  depressing  the  tin  over  the  cavity,  as  this 
would  make  the  pattern  too  large.  Cut  the  pattern  to  the  out- 
line thus  obtained,  and  test  its  accuracy  by  trial  in  the  cavity, 
then  cement  it  to  the  porcelain  by  placing  upon  the  latter  a 
grain  of  gum  shellac,  and,  holding  this  in  the  flame  of  the 
burner  until  the  gum  is  melted,  place  the  tin  pattern  on  the 
shellac  and  press  it  closely.  When  cool  it  will  be  found  to  be 
firmly  attached  and  the  surplus  porcelain  may  be  ground 
away,  leaving  the  disk  of  the  size  and  form  of  the  cavity. 
Then  reduce  the  thickness  until,  when  placed  in  position,  the 
disk  is  but  little  raised  above  the  surface  of  the  tooth. 

Having  the  disk  thus  prepared,  the  rubber  dam  applied  and 
the  cavity  dry,  mix  some  oxyphosphate  rather  thin,  so  that 
any  surplus  may  escape  around  the  filling,  then  partly  fill  the 
cavity  with  the  cement  and  press  the  porcelain  firmly  into 
place. 

*  Dr.  Whitefield,  in  Western  Electrician. 


90 


OPERATIVE    DENTISTRY. 


Gutta  percha  may  also  be  used  for  setting.  Use  a  soft 
o-rade  and  place  a  sufficient  quantity,  well  softened  by  heat, 
in  the  cavity,  and,  having  the  porcelain  also  well  heated,  press 
it  firmly  into  the  cavity,  from  which  the  surplus  gutta-percha 
will  flow  out  around  the  filling. 

Give  time  for  the  cement  or  gutta-percha  to  harden,  and 
then  grind  the  porcelain  to  proper  contour  and  polish  it. 

Some  prefer  to  grind  the  porcelain  a  little  smaller,  to  allow 
of  the  removal  of  a  portion  of  the  cement  or  gutta-percha, 
and  the  insertion  of  a  narrow  gold  fihing  around  the  margin. 


EROSION. 

The  affection  of  the  teeth  known  as  erosion  or  abrasion  is 
characterized  by  loss  of  substance.  It  appears  on  the  enamel 
in  irregular  patches  and  in  grooves  across  the  necks  of  the 
teeth,  these  spots  and  grooves  presenting  a  smooth  and  polished 
surface. 

The  upper  incisors  and  cuspids  are  the  most  frequently 
affected.  Other  classes  are  affected,  as  to  frequency,  in  the 
following  order:  upper  bicuspids,  lower  bicuspids,  cuspids  and 
incisors.  The  grinding  surfaces  of  molars  are  frequently 
attacked,  and  sometimes  the  cutting  edges  of  incisors. 

The  cause  is  unknown.  It  is  attributed  to  the  acid  secre- 
tion of  the  mucous  follicles,  to  defective  structure,  and  to  the 
use  of  stiff  brushes  and  coarse,  sharp  powders.  Weakened 
nervous  power  is  recognized  as  a  predisposing  cause. 

Treatment. — Make  the  secretions  healthy  and  advise  the 
moderate  and  regular  use  of  a  soft  tooth-brush  with  alkaline 
dentifrices.  No  powder  coarser  than  precipitated  chalk  should 
be  used.  Covering  the  teeth  at  night  with  a  paste  pf  phos- 
phate of  lime  is  advised,  but  nothing  has  yet  been  found  to 
entirely  arrest  its  progress.  When  far  advanced,  filling  is  the 
only  remedy,  and  this  will  not  prevent  its  extension. 

If  bicuspid  or  molar  teeth  are  much  affected,  a  gold  cap 
may  prove  serviceable. 


SENSITIVE    DENTINE. 


SENSITIVE  DENTINE. 


91 


Dentine  may  be  hypersensitive  in  all  parts  of  a  t<)(jth,  or 
only  in  isolated  spots.  A  line  near  the  ^um  on  the  surface  of 
the  tooth  is  frequently  affected. 

When  dentine  is  exposed  by  decay,  certain  portions  will  be 
found  unusually  sensitive.  The  location  of  these  sensitive 
areas  may  be  different  in  each  case,  but  the  most  sensitive 
points  will  be  found  somewhere  in  the  layer  of  dentine  next 
the  enamel. 

The  sensitiveness  arising  from  decay  may  always  be  lessened 
by  applications,  though  not  in  all  cases  entirely  overcome. 
The  most  useful  agent  is  dryness.  Use  the  hot-air  syringe 
(Fig.  82)  or  the  ordinary  chip-blower,  the  bulb  being  filled 
with  heated  air  by  drawing  in  the  flame  of  the  alcohol  lamp. 


Fig.  82. 


As  dryness  is  so  essential,  it  is  advised  to  apply  the  rubber 
dam,  when  practicable,  before  commencing  to  operate. 

Of  medicinal  agents  phosphoric  acid  is  probably  the  most 
effective.  That  its  effect  is  wholly  without  injury  to  the  den- 
tine, may  be  considered  as  still  in  doubt.  When  used,  be  sure 
to  remove  or  neutralize  all  the  acid  before  filling.  Cocaine, 
carbolic  acid,  creasote,  chloroform,  ether  spray,  glycerite  of 
tannin,  chloride  of  zinc,  nitrate  of  silver,  caustic  potassa  and 
bicarbonate  of  soda  in  solution  are  often  effective. 

Any  application  for  this  purpose  should  be  applied  to  the 
tlry  surface  and  allowed  to  remain  from  five  to  twenty  minutes, 
and  the  dentine  may  be  removed  as  far  as  the  sensitiveness  is 
destroyed,  when  the  application  must  be  repeated.  Phosphoric 
acid  and  zinc  chloride  usually  produce  more  or  less  pain  for 
a  short  time. 


92  OPERATIVE    DENTISTRY. 

The  following  is  the  formula  for  the  Herbst  obtundent : — 
Take  of — 

Sulphuric  acid I   drachm. 

Hydrochlorate  of  cocaine 30  grains. 

Sulphuric  ether 3  drachms. 

Dissolve  the  cocaine  in  the  acid  and  add  the  ether. 

The  following  is  excellent : — 
Take  of — 

Sulphuric  ether >    .    .  iK  Auidrachms. 

Cocaine  (alkaloid)    . 10  grains.  Mix. 

The  galvano-cautery  is  said  to  be  efficient  and  is  worthy  of 
trial.     It  should  be  passed  quickly  over  the  surface. 

Arsenions  acid  should  never  be  used  as  an  obtundent  of 
sensitive  dentine,  unless  it  is  determined  to  devitalize  the  pulp, 
as  this  result  is  sure  to  follow.  If  used,  the  pulp  should  be 
exposed  and  removed  at  once,  or  as  soon  as  possible,  to  avoid 
discoloration  of  the  tooth. 

SECONDARY   DENTINE. 

Dentine  which  is  formed  by  the  pulp  after  the  tooth  is  fully 
developed  is  called  secondary  dentine.  It  differs  in  its  struc- 
ture from  true  dentine,  the  tubuli  being  more  like  the  canaliculi 
of  bone.  The  tubuli  are  very  irregular,  without  any  centre  of 
radiation,  as  is  the  case  in  normal  dentine,  the  tubuli  of  the 
latter  radiating  from  the  pulp  cavity. 

The  tubuli  of  secondary  dentine  are  completely  filled  with 
calcific  material,  hence  it  is  very  translucent. 

It  is  formed  as  a  continuation  of  primary  dentine,  sometimes 
to  such  an  extent  that  the  pulp  is  nearly  obliterated.  In  other 
cases  it  is  deposited  in  isolated  nodules,  or  in  a  granular  form 
in  the  pulp  tissue. 

When  formed  as  a  covering  for  a  receding  or  nearly  exposed 
pulp  it  cannot  be  considered  pathological.  It  is  then  called 
protective  dentine,  or  dentine  of  repair,  but  when  it  is  produced 


SECONDARY    DENTINE.  93 

in  SO  great  quantities  as  to  cause  pressure  upon  the  pulp,  or  in 
irrc<Tular  forms  in  the  pulp,  it  assumes  a  pathological  char- 
acter. In  the  teeth  of  aged  persons,  the  crowns  of  which  are 
much  worn  down,  secondary  dentine  is  sure  to  be  formed,  and 
usually  round,  light-colored  s{)ots  may  be  seen,  showing  the 
places  formerly  occupied  by  the  cornua  of  the  pulp. 

Pulps  which  have  been  for  a  long  time  nearly  exposed,  or  to 
which  fillings  have  been  in  close  proximity,  frequently  contain 
nodules  or  granular  deposits.  Sometimes  a  single  nodule  takes 
the  form  of  the  pulp  cavity  and  nearly  fills  it. 

The  immediate  cause  of  secondary  dentine  is  an  irritation  of 
the  pulp,  the  remote  cause  being  the  source  of  this  irritation, 
as  the  abrasion  of  mastication,  the  force  of  occlusion  or  a 
blow;  and  while  it  is  a  result  of  irritation  it  finally  becomes  an 
irritant  to  the  pulp  which  formed  it,  hence  the  symptoms  are 
the  same  as  of  irritated  pulp,  but  more  persistent. 

When  formed  so  as  to  produce  these  pathological  conditions 
there  is  no  hope  of  recovery,  and  no  remedy  except  removal 
of  the  pulp. 

The  temporary  as  well  as  the  permanent  teeth  are  subject 
to  the  formation  of  secondary  dentine,  but  not  to  an  equal 
extent. 

Treatment. — Drill  into  the  tooth,  devitali/e  the  pulp  and 
remove  as  much  as  possible,  drill  any  remaining  portion  from 
the  canals,  and  fill  as  in  other  cases.  The  pulps  are  usually  so 
hard  in  these  cases  that  a  broach  will  not  pass  into  the  canals, 
and  the  drill  must  be  resorted  to,  and  often  when  the  pulp  is 
reduced  to  a  fine  line  health  and  comfort  cannot  be  obtained 
until  it  is  drilled  out. 

When  nodules  are  present  devitalize  the  pulp,  if  possible, 
and  remove  them.  If  sensitiveness  persists  after  the  use  of 
arsenic,  as  is  very  likely,  apply  sedative  obtundents  and  cut 
away  the  overlying  plate  of  dentine  until  the  aperture  is  large 
enough  to  permit  the  passage  of  the  nodule,  when  a  small  hook 
may  be  gradually  passed  by  and  the  nodule  drawn  out.  The 
sensitiveness  of  the  pulp  is,  in  such  cases,  very  persistent,  and 


94 


OPERATIVE    DENTISTRY. 


great   patience    must   be    exercised    in  its   devitalization  and 
removal. 

THE  DENTAL  PULP. 

The  following  are  conditions  of  the  healthy  pulp  needing 
treatment : — 

Sensitive  Pulp. — Decay  has  nearly  reached  the  pulp,  and 
the  dentine  over  that  portion  is  especially  sensitive  to  the  light 
touch  of  an  instrument,  and  these  are  the  signs  by  which  the 
condition  is  recognized. 

Treatment. — Bathe  freely  with  wood  creasote,  and  after 
absorbing  the  surplus  cover  the  sensitive  parts  with  pre- 
pared chalk  Sometimes  strong  carbolic  acid  is  used  instead 
of  creasote.  Place  upon  this  some  non-conducting  and  non- 
irritating  substance,  as  asbestos,  gutta-percha  dissolved  in 
chloroform,  or  oxyphosphate  of  zinc,  and  over  this  insert  the 
permanent  filling,  avoiding  pressure  over  the  sensitive  parts. 

Partially  Exposed  Pulp. — In  this  case  the  overlying  den- 
tine is  partially  decalcified  and  generally  more  or  less  discol- 
ored. The  symptoms  differ  from  those  of  sensitive  pulp  only 
in  degree,  and  the  condition  must  be  recognized  by  physical 
signs,  especially  by  extent  of  decay  and  by  touch. 

Treatment. — Leave  a  portion  of  the  partially  decalcified  den- 
tine over  the  pulp  for  protection  and  treat  as  described  for  sen- 
sitive pulp. 

Exposed  Pulp. — Symptoms. — The  pulp  is  sensitive  to  touch. 
It  appears  as  a  small  grayish-white  spot  in  the  dentine,  and 
may  be  detected  by  sight,  or  by  the  very  delicate  touch  of  a 
fine-pointed  instrument. 

Treatment. — Cap  the  pulp  with  a  solution  of  gutta-percha  in 
chloroform,  adding  oxyphosphate  or  oxychloride  of  zinc  for 
protection,  the  latter  mixed  thin  and  applied  without  pressure, 
or  bathe  the  exposed  pulp  for  some  minutes  with  creasote,  and 
then  cap  with  oxyphosphate  of  zinc. 

A  method  much  in  favor  with  some  is  to  cap  the  pulp  with 
a  paste  of  creasote  or  carbolic  acid  and  oxide  of  zinc,  placing 


THE    DENTAL    PULP.  95 

over  this,  for  protection,  a  portion  of  the  oxychloride.     J'^ill  the 
cavity  with  any  material  desired. 

DISEASES    OI'   THE    I'UI.P. 

Irritation.  Congestion,  Inflammation. 

Fungus.  Sui)puration. 

Fatty  degeneration.  Calcification. 

Atrophy.  Mummification. 
Putrescence. 

Mummification  and  putrescence  are  conditions  resulting 
from  disease. 

Irritation. — Symptoms. — Sensibility  becomes  very  much 
exalted — a  state  of  hypercnesthesia ;  the  pulp  is  easily  excited, 
but  pain  produced  soon  subsides. 

Treatment. — Subdue  the  irritation  with  creasote,  oil  of 
clove,  chloroform,  or  equal  parts  of  creasote  and  oil  of  clove. 
Unless  the  irritation  borders  on  inflammation,  insert  oxy- 
phosphate  at  once  and  let  it  remain  several  weeks  ;  then,  if  no 
trouble  arises,  insert  the  permanent  filling.  If  in  the  meantime 
pain  arises,  remove  the  temporary  filling  and  treat  the  pulp 
for  congestion  or  inflammation. 

Congestion  and  Inflammation. — The  essential  feature  of 
congestion  is  an  undue  fullness  of  the  blood  vessels  with 
the  return  flow  of  blood  retarded.  Sensibility  is  not  much 
increased,  and  pain  is  not  severe,  but  is  dull  and  heavy.  If 
the  congested  organ  is  wounded,  blood  flows  freely. 

In  inflammation,  the  amount  of  blood  is  still  greatly 
increased,  with  complete  stasis  at  some  point,  accompanied  by 
effusion  and  exudation  through  the  walls  of  the  vessels.  Pain 
becomes  sharp,  severe  and  paroxysmal,  and  often  throbbing. 
There  is  extreme  sensibility  to  touch  and  to  thermal  changes. 

Treatment. — A  congested  or  inflamed  pulp  is  very  unlikely 
to  become  healthy.  If  quiet  for  a  time,  it  gradually  loses  its 
vitality  and  sooner  or  later  gives  trouble,  but  an  effort  should 
be  made  to  save  it,  and  in  some  favorable  cases  success  may 
be  obtained.  Cleanse  and  dry  the  cavity,  and  apply  creasote 
and  oil  of  clove  to  allay  the  sensibility  and  pain.     If  neces- 


96  OPERATIVE    DENTISTRY. 

sary,  for  the  relief  of  pain,  prick  the  pulp  and  allow  it  to  bleed; 
then  apply  creasote  and  cover  with  cotton  and  sandarac  var- 
nish, or  a  mixture  of  equal  parts  pink  gutta-percha  and  bees- 
wax, sealing  the  cavity  perfectly.  Change  the  dressing  daily 
until  the  pulp  is  apparently  restored  to  health,  then  cap  and 
fill  temporarily. 

If  the  pulp  cannot  be  made  healthy,  or  if  the  diseased  con- 
dition recurs,  devitalize  and  remove  it. 

The  presence  of  nodules  of  secondary  dentine  in  the  pulp 
renders  it  very  difficult,  or  quite  impossible,  to  relieve  the 
inflammation,  and  devitalization  and  removal  is  the  only 
remedy. 

If  the  pulp  develops  a  fungous  growth,  the  application  of  a 
little  strong  nitric  acid  will  destroy  it  with  but  little  pain. 
Dry  the  pulp,  and  with  a  wood  toothpick  apply  a  drop  of  the 
acid. 

Remove  at  once  all  mummified,  calcified,  atrophied,  fatty 
and  putrescent  pulps. 

Devitalization  of  the  Pulp. — If  painful,  quiet  with  crea- 
sote, or  better,  with  creasote  and  oil  of  clove,  equal  parts. 
Arsenic  increases  the  pain.  After  remaining  twenty-four  hours 
free  from  pain,  or  nearly  so,  apply  arsenic  as  follows  :  Take  a 
pellet  of  cotton  the  size  of  a  pin-head  on  a  small  excavator  and 
saturate  with  creasote;  touch  the  cotton  to  some  substance  to 
absorb  the  excess  of  creasote,  then  touch  to  the  powder  of 
arsenious  acid,  taking  what  will  adhere  to  one  side  of  the 
pellet.  One-fiftieth  of  a  grain  is  sufficient.  Apply  this  accu- 
rately to  the  exposed  portion  of  pulp  and  cover  with  gutta- 
percha and  wax,  or  cotton  and  sandarac  varnish.  Avoid 
pressure. 

Instead  of  pure  arsenic  the  following  may  be  used : — 

Arsenious  acid ~| 

Tannic  acid I  Equal  parts. 

Sulphate  or  acetate  of  morphia ) 

Mix  thoroughly. 

It  is  important  to  fully  expose  some  portion  of  the  pulp,  to 


THE    DENTAL    PULP.  97 

allow  blood  or  scruiii  to  escape,  and  thus  prevent  pain  from 
con<^estion,  and  also  prevent  discoloration  of  the  tooth  from 
infiltration  of  the  coloring  matters  of  blood  into  the  dentine. 

The  arsenic  must  not  be  allowed  to  touch  the  parts  around 
the  tooth,  as  serious  slou'^hin^  of  the  soft  parts  and  exfoliation 
of  bone  may  result  from  its  action. 

In  many  cases  arsenic  will  effect  the  devitalization  of  the 
pulp  in  six  hours  or  in  less  time,  but  it  may  usually  remain 
twenty-four  hours,  and  if  the  pulp  has  resisted  its  action,  as 
much  of  it  as  practicable  may  be  removed  and  the  application 
repeated.  If  allowed  to  remain  several  days  or  even  weeks, 
ordinarily  no  harm  will  result. 

Removal  of  the  Pulp. — After  devitalization,  cut  away  the 
dentine  with  excavators,  chisels,  or  burs,  so  as  to  obtain  free 
access  to  the  pulp  cavity,  then  remove  the  pulp  with  barbed 
broaches  or  hooks.  Press  the  pulp  gently  to  one  side  and 
pass  the  broach  up  the  canal  as  far  as  possible.  Pushing  upon 
the  pulp  should  be  avoided,  as  it  produces  more  pain  than 
traction. 

If  the  pulp  be  treated  for  a  few  days  with  tannic  acid  and 
creasote  it  may  generally  be  removed  entire,  but  sometimes  it 
will  be  more  or  less  broken  up,  and  any  remaining  shreds  may 
be  removed  with  a  little  cotton  wound  on  a  broach  and  rotated 
in  the  canal. 

The  conical  reamer  will  be  found  valuable  to  enlarge  the 
opening  of  the  canal,  if  needed,  to  more  conveniently  reach  the 
apex. 

If  the  pulp  is  not  readily  accessible  through  a  cavity  of 
decay,  drill  through  the  lingual  surface  of  incisors  or  cuspids 
or  the  grinding  surface  of  bicuspids  and  molars,  though  some- 
times in  inferior  bicuspids  it  is  better  to  drill  through  the 
buccal  surface  at  the  neck  of  the  tooth. 

Frequently  an  inflamed  pulp  will  prove  very  resistant  to  the 
action  of  arsenic  or  of  sedatives,  and  many  sittings  will  be 
required  to  accomplish  its  removal,  and  in  many  cases  peri- 
cemental inflammation  will  be  excited  before  the  sensitiveness 


98  OPERATIVE    DENTISTRY. 

of  the  pulp  is  destroyed.  For  this  there  is  no  remedy  known, 
except  the  continued  application  of  sedatives.  Slight  pressure 
upon  pulp  tissue  which  is  dead  or  even  putrescent,  will  some- 
times produce  pain ;  this  is  due  to  the  communication  of  the 
pressure  to  the  inflamed  tissue  beyond.  In  these  cases  the 
dead  tissue  should  be  gently  draivn  atvay  with  small  excava- 
tors or  hooks. 

In  children's  teeth  be  careful  "to  not  pass  the  instruments 
used  in  the  removal  of  the  pulp  through  the  foramen,  as  it  is 
large. 

Extirpation  of  Pulp  by  Operation. — The  pulp  may  be 
removed  by  immediate  extirpation  by  means  of  a  barbed 
broach,  or  by  a  drawn-temper  nerve  needle  with  the  point  bent 
to  form  a  small  hook. 

After  fully  exposing  the  pulp,  press  it  to  one  side  with  an 
excavator,  and  pass  the  instrument  up  between  the  pulp  and  the 
wall  of  the  canal  as  far  as  possible,  then  rotate  the  instrument 
to  entangle  the  pulp,  and  withdraw  the  instrument,  bringing 
the  pulp  with  it.  This  operation  may  be  rendered  less  painful 
by  the  application  of  atropine,  chloroform,  carbolic  acid,  or 
cocaine.  While  this  method  may  often  prove  successful  with- 
out much  pain,  yet  in  the  majority  of  cases  an  anaesthetic  will 
be  necessary. 

General  Anaesthesia  in  Removal  of  the  Pulp. — Nitrous 
oxide  gas  will  usually  be  preferred  for  this  operation.  Cut 
into  the  tooth  at  some  point  from  which  the  pulp  canal  is 
accessible,  as  deeply  as  the  sensitiveness  of  the  tooth  will 
permit.  Have  the  engine  at  hand  armed  with  a  sharp,  round 
bur.  No.  6  or  7,  and  also  instruments  for  the  removal  of  the 
pulp.  Then  give  the  gas,  and  during  the  anaesthesia  drill  into 
the  pulp  chamber,  enlarge  the  opening  until  the  canal  can  be 
readily  entered,  and  with  the  nerve  instruments  remove  the 
pulp. 

A  method  practiced  to  some  extent,  and  often  successful 
when  there  remains  a  considerable  portion  of  the  crown,  is  as 
follows  :     With  a  bur  in  the  engine,  cut  a  deep  channel  around 


PREPARATION    OF    ROOTS    FOR    FILLING. 


99 


the  neck  of  the  tooth.  Have  at  hand  a  piece  of  orange  wood 
or  hickory,  vvliittled  at  the  point  to  about  the  size  and  form  of 
the  root  canal,  then  with  a  pair  of  excising  forceps  (Fig.  83), 


Fig.  83 


the  beaks  placed  in  the  channel,  cut  off  the  crown.  Imme- 
diately insert  the  wood  point  by  the  side  of  the  remaining 
pulp  and  drive  it  gently,  but  thoroughly,  into  the  canal  with 
the  mallet,  turn  the  point  around  and  remove  it,  and  the 
crushed  pulp  will  be  found  adhering  to  its  surface.  The 
shock  of  the  excision  so  benumbs  the  pulp  that  the  operation 
is  nearly  or  quite  painless. 


PREPARATION  OF  ROOTS  FOR  FILLING. 

After  the  complete  extirpation  of  the  pulp,  the  root  canals 
will  need  but  little  further  preparation  for  filling.  For  con- 
venience the  canals  may  be  enlarged  one-quarter  to  one-third 
of  their  length,  but  canals  in  roots  of  normal  form  and  con- 
dition need  never  be  enlarged,  and  are  better  filled  without. 

If  the  foramen  is  found  to  be  large,  so  that  an  instrument 
may  pass  through,  measure  the  length  of  the  root  with  a  fine 
hook   broach  passed  through  the  foramen,  and  drawn  back 
until  the  hook  catches  on  the  end  of  the  root.     Mark 
this  length   from  the  surface  on  the  instrument  by  a    ^"^-  ^*- 
small  bit  of  rubber  dam  through  which  the  instrument 
was  previously  passed.     Remove   the  broach,   then, 
with  a  drill  a  little  larger  than  the  foramen,  the  length 
being  marked  in  the  same  manner,  but  a  little   less 
than  the  first,  enlarge  the  canal  to  this  extent,  thus 
leaving  a  square  shoulder  near  the  foramen.    (Fig.  84.) 

Insure  a  healthy  condition  of  the  tooth  and  surrounding 
tissues. 


lOO 


OPERATIVE    DENTISTRY, 


Fig.  85. 


If  a  broach  or  drill  should  be  broken  off  in  the  root  canal, 
an  accident  which  occasionally  occurs,  the  broken  end  may 

be  removed,  if  the  canal  is  large 
and  accessible,  by  passing  an- 
other broach  at  one  side  and 
beyond  it  and  drawing  it  out,  or 
it  may  be  grasped  and  drawn 
out  by  the  canal  pliers  shown  in 
Fig.  85.  In  many  instances  it  will 
be  found  impossible  to  remove 
it  by  any  mechanical  means.  In 
such  cases  fill  the  canal  with 
strong  tincture  of  iodine,  seal 
the  cavity  with  gum  sandarac 
on  cotton,  and  in  a  few  days  the 
iron  will  be  found  reduced  to  an 
oxide,  when  it  may  be  removed 
by  breaking  up  or  drilling. 


FILLING   ROOTS   OF   TEETH. 

Roots  may  be  filled  with  gold, 
tin,  gutta-percha  or  oxychloride 
of  zinc. 

Gold  or  tin  foil,  rolled  into 
points  having  about  the  size  and 
form  of  the  canal,  one-fourth  to 
one-third  of  an  inch  in  length, 
may  be  used  to  fill  the  apex  of 
the  root,  being  carried  to  place 
by  a  fine  canal  plugger  and 
gently  but  firmly  malleted.  Con- 
tinue until  the  upper  third  of  the 
root  is  solidly  filled. 
Gutta-percha  is  used  dissolved  in  chloroform  and  carried 
up,  by  means  of  cotton  wound  on  a  broach,  until  the  root  is 


I5LEACH1NG    DISCOLORED    TEETH.  lOl 

filled;  but  this  remains  soft  and  porous.  Abetter  method  of 
usiui^  gutta-percha  is  to  roll  it,  while  warm,  into  properly- 
shaped  points,  as  directed  for  gold,  and,  when  cold,  dip  in 
chloroform  and  press  or  mallet  to  place. 

Oxychloride  of  Zinc. — Mix  this  thin  like  cream,  and,  with 
a  fine  broach  wound  with  cotton  and  dipped  in  the  cement, 
carry  it  to  the  apex  of  the  root ;  repeat  the  process,  and  gradu- 
ally the  whole  root  may  be  filled. 

Oxyphosphate  of  zinc  is  an  excellent  material  for  filling 
roots  and  pulp  chambers,  but  its  sticky  quality  renders  it  diffi- 
cult to  carry  it  to  the  apex  of  a  small,  tortuous  canal,  and  for 
the  apical  portion  it  is  better  to  use  some  other  material. 

To  fill  a  canal  with  an  open  foramen,  prepare  a  cylinder  of 
gold  or  gutta-percha,  with  square  end  the  size  of  the  canal, 
which  has  been  previously  enlarged  nearly  to  the  apex,  and 
press  or  mallet  gently  to  place,  as  before  described,  using  as 
large  a  plugger  as  will  pass  up  the  canal. 

Cotton,  in  a  small  thread  saturated  with  oxychloride  of  zinc, 
is  successfully  used  to  fill  root  canals,  and  by  many  this  is 
thought  to  be  the  best  method. 

The  pulp  chamber  may  in  all  cases  be  filled  with  cement. 


BLEACHING   DISCOLORED   TEETH. 

In  bleaching  teeth  discolored  from  internal  causes  the  essen- 
tial feature  of  the  process  is  the  removal  of  the  discolored 
dentine  from  the  interior  of  the  tooth  and  the  filling  of  the 
cavity  with  light-colored  oxychloride  of  zinc.  To  do  this, 
drill  through  the  palatal,  lingual  or  grinding  surface,  if  no 
cavity  already  exists,  and  with  burs  and  excavators  remove  as 
much  as  is  possible  and  safe  of  the  discoloration,  sometimes 
leaving  only  the  enamel  walls.  Fill  with  oxychloride  of  zinc, 
and  allow  it  to  harden  ;  then  fill  the  orifice  of  the  cavity  with 
permanent  filling. 

Chemical  reagents  may  be  used  in  the  cavity  for  bleaching. 

"  Fill  the  cavity  with  chlorinated  lime;  then  wet  this  with 


I02  OPERATIVE    DENTISTRY. 

water  8  parts,  acetic  acid  i  part.  This  liberates  chlorine, 
which  bleaches  the  tooth.  The  orifice  of  the  cavity  should 
be  stopped  with  cotton  or  wax,  to  confine  the  liberated  gas. 

"  This  need  not  remain  longer  than  fifteen  minutes,  when 
another  application  may  be  made,  if  needed.  Two  or  three 
applications  will  accomplish  all  that  should  be  expected."  * 

"Another  method  is:  Take  lOO  grains  sodium  sulphite 
and  70  grains  boracic  acid,  both  carefully  dried  and  ground 
together,  in  a  warm,  dry  mortar,  to  a  fine  powder.  Place 
some  of  this  powder  in  the  cavity,  add  a  drop  of  water,  and 
stop  the  orifice  temporarily;  or  take  of  sodium  sulphite  lOO 
grains,  boric  oxide  55  grains.  Prepare  and  use  as  above 
described." 

"  Another  method :  Wash  the  cavity  repeatedly  with  per- 
oxide of  hydrogen,  dry  thoroughly  with  hot  air.  Place  a 
small  quantity  of  aluminum  chloride  in  the  cavity,  and  wet 
it  with  peroxide  of  hydrogen.  Allow  this  to  remain  five 
minutes,  and  then  wash  out  the  cavity  with  water."  f 

"Another :  Wash  the  cavity  with  a  solution  of  permanganate 
of  potash;  then. use  alternately  a  four  per  cent,  solution  of 
sulphuric  acid  and  Labarraque's  solution.  Repeat  for  a  few 
minutes ;  then  dry  the  cavity,  and  it  is  ready  for  the  filling."  X 


TREATMENT   OF   FIRST   MOLARS. 

The  first  molars  are  the  largest  teeth  in  the  mouth  and  have 
the  largest  roots.  If  of  good  quality,  they  are  the  strongest 
teeth,  but  they  are  frequently  faulty  in  structure  or  imperfectly 
developed.  Often  there  are  small  pits  or  holes  in  the  enamel 
and  fissures  on  the  grinding  surface,  leaving  the  dentine 
exposed  to  decay.  Sometimes  they  are  so  poor  that  decay 
begins  immediately  after  their  eruption,  and  they  fail  entirely 


*  Dr.  Kirk.     "  American  System  of  Dentistry." 
f  Dr.  Harlan.     "  American  System  of  Dentistry." 
J  Dr.  Regester.     "American  System  of  Dentistry." 


TKKATMKNT    OF    FIRST    MULAKS.  IO3 

before  the  patient  is  aware  of  clanger.  Being  erupted  at  the 
age  of  six  years,  they  are  often  mistaken  for  temporary  teeth, 
and  are  neglected  on  this  account. 

The  treatment  of  these  teeth  should  depend  upon  several 
considerations  : — 

First.  The  quality  of  the  teeth. 

Second.  The  probabilit}^  of  saving  them  permanently  or 
temporarily  until  the  eruption  of  the  second  molars,  without 
an  unreasonable  amount  of  attention. 

If  the  teeth  are  well  developed  and  of  good  structure,  wo 
may  expect  to  save  them  as  well  as  any  teeth  in  the  mouth ; 
but  if  poor,  it  may  be  unreasonable  to  attempt  to  retain  them 
beyond  the  time  of  the  eruption  of  the  second  molars. 

The  arguments  in  favor  of  saving  these  teeth  are  : — 

First.  The  avoidance  of  the  shock  of  extraction. 

Second.  The  greater  certainty  of  the  full  development  of 
the  jaw,  and  a  more  perfectly  normal  occlusion  of  the  teeth. 

Third.  Their  great  value  as  masticators,  especially  until  the 
eruption  of  the  bicuspids  and  second  molars. 

The  arguments  in  favor  of  early  extraction  are  : — 

First.  Much  severe  experience  in  the  operating  chair  is 
spared  to  the  patient  under  the  stress  of  having  teeth  filled 
at  an  age  when  such  operations  are  not  well  borne  and  the 
courage  is  often  broken,  in  consequence  of  which  much  injur\- 
comes  to  the  other  teeth  from  neglect. 

Second.  Room  is  gained  for  the  anterior  teeth  to  become 
somewhat  separated,  as  they  usuall)'  will,  and  so  be  rendered 
less  liable  to  caries. 

Third.  Room  is  afforded  for  the  more  perfect  development 
of  the  second  and  third  molars. 

Fourth.  If  the  teeth  are  irregular  from  crowding,  room  is 
given  for  self-regulation. 

Unless  the  quality  of  these  teeth  is  so  poor  as  to  render  it 
impracticable,  they  should  be  preserved  until  just  before  the 
time  for  the  eruption  of  the  second  molars,  so  that  these  may 
come  forward  and  take  the  place  of  those  extracted.     This 


I04  OPERATIVE    DENTISTRY. 

should  be  done,  even  if  it  necessitates  the  removal  of  the  pulp 
and  the  filling  of  the  root  canals. 

The  plastic  fillings  should  be  used  in  these  teeth  for  their 
preserv^ation  until  it  is  fully  determined  whether  they  are  to 
be  permanently  saved  or  lost,  and  until  the  patient  is  well  able 
to  bear  the  operations  required  for  the  insertion  of  permanent 
fillings. 

Third  Molars. — These  teeth  are  valuable  to  the  patient 
when  they  are  of  good  quality,  in  proper  position  and  have 
sufficient  room  in  the  jaw. 

The  upper  third  molar  is  frequently  out  of  position,  pro- 
jecting toward  the  cheek  and  proving  a  source  of  constant 
irritation.     In  such  cases  it  should  be  extracted. 

The  lower  third  molar  frequently  fails  of  complete  eruption 
from  lack  of  room  at  the  angle  of  the  jaw,  and  in  consequence 
of  this  the  overlying  tissue  is  kept  in  a  state  of  constant  irri- 
tation, and  often  serious  inflammations  result.  In  these  cases, 
if  either  the  first  or  the  second  molar  is  much  decayed  and  the 
third  molar  is  of  good  quality,  extract  the  first  or  second,  and 
thus  allow  the  third  to  move  forward  and  relieve  the  pressure, 
otherwise  extract  the  third  molar. 

TREATMENT  OF  THE  TEMPORARY  TEETH. 

The  treatment  of  the  temporary  teeth  should  be  governed 
by  the  same  general  principles  as  that  of  the  permanent  teeth. 
If  decayed,  they  should  be  filled  and  preserved,  if  possible, 
until  they  are  shed  by  the  process  of  absorption. 

Their  preservation  is  desirable  for  the  following  considera- 
tions : — 

First. — Their  service  in  mastication. 

Second. — The  prevention  of  disfigurement. 

Third. — The  greater  certainty  of  thus  insuring  a  more 
perfect  development  of  the  permanent  set. 

Fourth. — The  prevention  of  suffering  from  toothache  and 
from  extraction  before  the  roots  are  absorbed. 


TRKAT.MENT    OK    THE    TEMPORAKV    TF.F.TH.  IO5 

Cleanliness  is  essential  to  the  welfare  of  these  teeth,  and 
children  should  be  encourag^ed  to  use  the  brush  at  as  early  an 
age  as  they  are  capable,  and  previous  to  this  time  the  nurse  or 
the  mother  may  use  it  for  the  child,  to  the  great  advantage  of 
the  teeth. 

It  is  unwise  to  attempt  to  perform  as  thorough  operations 
upon  the  temporary  teeth  as  upon  the  permanent,  and  it  is 
seldom  possible,  as  the  teeth  are  friable  and  their  support  in 
the  jaw  weak,  and  patients  at  this  tender  age  cannot  well  bear 
the  discomfort  of  dental  operations. 

Plastic  fillings  only  should  be  used  for  these  cases.  For  the 
anterior  teeth  oxyphosphate  of  zinc  or  gutta-percha  is  best, 
and  for  the  molars  amalgam  serves  an  excellent  purpose  when 
the  cavity  is  well  formed  ;  but  if  very  shallow,  or  the  pulp  is 
nearly  exposed,  oxyphosphate  is  better. 

If  a  pulp  is  exposed  and  painful,  quiet  with  sedatives,  de- 
vitalize with  tannic  acid  and  creasote,  remove  as  much  of  the 
pulp  as  possible  and,  placing  a  piece  of  small  pin  through  the 
cavity  into  the  pulp  chamber,  fill  the  cavity  around  the  pin, 
and  when  the  filling  is  finished,  remove  the  pin,  leaving  the 
hole  as  a  vent  from  the  pulp  chamber ;  or  fill  the  cavity  and 
then  drill  a  small  hole  just  beneath  the  margin  of  the  gum 
into  the  pulp  cavity  for  a  vent.  •  It  is  usually  quite  impracti- 
cable to  fill  the  roots  of  these  teeth. 

Exposed  pulps  in  these  teeth,  if  not  painful,  maybe  covered 
with  tannic  acid  and  glycerine  on  a  soft  pellet  of  cotton,  filling 
over  this  with  cement  without  pressure.  Thus  treated,  they 
will  remain  quiet  for  an  indefinite  time.  This  treatment  is  not 
applicable  to  permanent  teeth. 

It  is  good  practice  to  dress  off  the  distal  surface  of  the  sec- 
ond temporary  molar  to  preserve  the  first  permanent  molar 
from  decay.  It  is  also  wise,  whenever  practicable,  to  dress 
away  the  other  proximal  surfaces  of  the  temporary  molars  and 
thus  render  them  less  liable  to  caries. 

When  abscess  forms,  it  may  often  be  necessary  to  remove 
a  tooth  for  the  relief  of  pain ;  but  if  the  abscess  has  become 
8 


I06  OPERATIVE    DENTISTRY. 

chronic  and  gives  the  patient  Httle  or  no  annoyance,  the  tooth 
may  be  allowed  to  remain  until  there  are  other  indications  for 
its  removal. 

HYPERCEMENTOSIS. 

This  affection  of  the  teeth  is  hypertrophy  of  the  cenientiim. 
It  often  produces  great  enlargement  of  the  roots,  rendering 
extraction  difficult  and  occasionally  impossible.  It  is  more 
common  near  the  apex  of  the  root,  but  it  may  appear  on  any 
part  of  the  cementum  and  assume  a  variety  of  forms. 

The  cause  is  obscure.  It  may  result  from  local  irritation  of 
the  pericementum,  from  want  of  occlusion  or  from  syphilis. 

Treatment. — No  treatment  is  known  that  will  cure  it,  and  if 
productive  of  pain  to  the  patient,  extraction  affords  the  only 
relief;  but  some  think  the  administration  of  iodide  of  potas- 
sium may  afford  relief  by  producing  resorption  of  bone  to 
make  room  for  the  tumor. 

PERICEMENTITIS. 

Inflammation  of  the  Pericementum  is  acute  or  chronic, 
according  as  it  is  recent  or  of  long  standing. 

The  symptoms  in  the  earlier  stages  are  sensitiveness  to 
thermal  changes,  a  feelinar  ofc  uneasiness  and  of  tension  or  full- 
ness,  with  a  desire  to  press  the  teeth  together,  this  affording 
temporary  relief  Soon  the  tooth  seems  longer  than  the  others, 
and  occlusion  gives  great  pain.  In  the  later  stages  the  gums 
become  red,  tender,  and  swollen,  and  these  latter  symptoms  are 
accompanied  by  dull,  heavy  pain,  which  may  become  very 
severe. 

Acute  Pericementitis  may  continue  but  a  few  hours,  or  it 
may  take  several  days  to  run  its  course. 

An  attack  of  acute  pericementitis  is  very  likely  to  result  in 
the  chronic  form.  In  such  cases  the  tooth  will  suffer  severe 
exacerbations  of  the  disease  from  any  slight  cause,  such  as 
cold  or  injury,  with  periods  of  rest  of  varying  length  between, 
during  which  the  tooth  seems  entirely  well. 


PER  I  CEMENT  IT  IS.  lO/ 

Acute  pericementitis  may  terminate  by  resolution  and  per- 
fect recovery  follow,  or  it  may  assume  a  chronic  form  and  con- 
tinue indefinitely,  but  if  unchecked  in  its  course  its  termination 
will  be  alveolar  abscess. 

Pericementitis  is  caused  usually  by  an  inflamed  or  otherwise 
diseased  or  disorganized  pulp.  It  may  be  caused  also  by  a  blow, 
hard  Ijiting  or  other  violence,  by  calculus  or  other  foreign  sub- 
stance about  the  neck  of  the  tooth,  or  it  may  result  from  the 
systemic  effects  of  mercury. 

Treatment. — Remove  the  cause  and  then  protect  the  tooth 
from  occlusion  by  a  cap  of  gutta-percha  over  some  other  tooth, 
and  thus  give  it  rest. 

If  the  pulp  is  diseased  restore  it  to  health  or  devitalize  and 
remove  it.  If  it  is  disorganized,  remove  it,  and  thoroughly 
disinfect  the  cavity  and  canals.  Remove  all  calculus  or  other 
foreign  substance  from  the  neck  and  roots  of  the  tooth.  With 
a  small  pellet  of  cotton  wound  upon  the  end  of  a  wood  tooth- 
pick, or  with  a  camel's-hair  brush,  paint  upon  the  gum  tincture 
of  iodine,  or  equal  parts  tincture  of  iodine  and  tincture  of 
aconite  root,  or  (\xy  the  gum  and  apply  capsicum  plasters  or 
bags,  or  cantharidal  collodion. 

Give  saline  cathartic,  as  citrate  or  sulphate  of  magnesia. 

The  same  treatment  applies  to  chronic  pericementitis,  and 
it  should  be  repeated  as  occasion  requires. 

Phagedenic  Pericementitis. — The  form  of  pericementitis 
which  commences  at  the  margin  of  the  gum  and  progresses 
downward  upon  the  root  of  the  tooth  has  long  been  recognized, 
but  special  attention  was  called  to  the  disease  and  its  treatment 
by  the  late  Dr.  Riggs,  and  it  has  since  been  known  as  Riggs' 
Disease.  It  is  also  known  as  pyorrhoea  alveolaris,  but  the  term 
phagedenic  pericementitis  has  been  more  recently  proposed, 
and  as  it  is  received  with  favor  and  is  expressive  of  a  condition 
which  obtains  throughout  the  entire  course  of  the  disease,  it  is 
adopted  in  this  place. 

It  usually  begins  on  a  single  surface  of  the  tooth,  or  upon  a 
small  spot  only,  but  it  may,  in  the  early  stages,  affect  the  tissues 


I08  OPERATIVE    DENTISTRY. 

throughout  the  entire  circumference  of  the  tooth.  It  may  also, 
in  the  beginning  be  confined  to  a  single  tooth,  attacking  others 
consecutively,  or  it  may  affect  several  or  all  of  the  teeth  in 
the  mouth  at  the  same  time. 

When  the  inflammation  starts  from  a  single  spot  it  forms  a 
pocket  under  the  gum  by  the  destruction  of  the  pericementum 
and  alveolar  wall.  These  pockets  may  reach  to  the  apex  of 
the  roots  and  include  only  a  small  portion  of  the  circum- 
ference. 

When  the  whole  circumference  is  involved  at  first  the  mar- 
gins of  the  gum  and  alveolar  walls  gradually  waste  away, 
leaving  the  neck  and  root  of  the  tooth  exposed  as  the  disease 
progresses,  until  the  connection  of  the  tooth  with  the  jaw  is 
destroyed,  and  the  tooth  falls  out  for  want  of  support. 

Often  a  single  surface,  the  buccal  or  lingual,  may  be  exposed 
to  the  apex  and  the  remaining  parts  continue  comparatively 
healthy. 

At  the  beginning  of  the  disease  there  is  increased  redness, 
accompanied  by  a  thickening  of  the  margin  of  the  gums, 
their  color  becomes  purplish,  the  gum  loosens  from  the 
neck  of  the  tooth,  and  beneath  it  is  an  accumulation  of  serum 
and  saliva,  mucus  and  cast-off  epithelial  scales.  This  accu- 
mulation is  irritating,  and  hence  its  presence  hastens  the  pro- 
gress of  the  disease.  At  this  stage  the  alveolar  walls  begin  to 
be  affected  and  to  waste  away,  and  necrosis  may  occur  to  some 
extent.  In  the  more  advanced  stage  of  the  disease  pus  is 
•  formed,  and  if  pressure  be  applied  to  the  gum  the  pus  may  be 
seen  to  ooze  out  around  the  neck  of  the  tooth.  In  some  cases 
in  which  many  teeth  are  severely  affected  the  discharge  of  blood 
and  pus  is  so  great  as  to  weaken  the  patient  and  seriously 
impair  the  general  health. 

The  disease  may  be  the  result  of  local  irritation  or  of  sys- 
temic conditions,  the  local  irritation  being  produced,  in  most 
cases,  by  salivary  calculus,  but  any  foreign  substance,  as  a  liga- 
ture or  rubber  band  around  the  tooth,  or  a  bristle  from  the 
tooth  brush,  may  produce  it. 


PERICEMENTITIS.  IO9 

After  the  disease  has  made  some  progress  the  deposit  of 
serumal  calculus  increases  its  severity  and  extent. 

In  some  cases  it  occurs  and  goes  on  to  the  destruction  of 
the  pericementum  and  alveolar  process  without  the  presence 
of  calculus  or  any  other  irritant  so  far  as  can  be  observed. 
Syphilis  seems  to  induce  this  form  of  the  disease. 

TnatDioit. —  The  essential  treatment  is  surgical,  and  consists 
in  the  entire  removal  of  all  calcareous  or  other  deposits  from 
the  teeth,  as  described  on  page  54,  and  of  any  diseased  por- 
tion of  the  alveolar  process,  and  a  thorough  removal  of  all 
debris  from  beneath  the  gum.  In  cases  in  which  calcareous 
deposits  are  absent  the  alveolar  wall  is  affected  and  the  surgical 
treatment  should  be  directed  to  the  removal  of  the  diseased 
portion.  The  treatment  should  be  repeated  at  intervals  of  one 
week  until  the  disease  is  cured  or  it  becomes  evident  that  fur- 
ther improvement  is  hopeless. 

Medicinal  agents  locally  applied  exert  a  beneficial  influence 
and  hasten  the  cure.  These  are  most  conveniently  and  effect- 
ively applied  with  a  syringe  having  a  long,  fine  tube,  which 
may  be  passed  down  by  the  side  of  the  root  and  the  medicine 
applied  at  the  seat  of  the  disease. 

Usually,  mild  remedies  are  sufficient,  but  sometimes  caus- 
tics, such  as  the  sulphate,  chloride  or  iodide  of  zinc,  nitrate  of 
silver  or  deliquesced  carbolic  acid  may  be  required.  Aromatic 
sulphuric  acid  or  tincture  of  iodine  may  be  used,  full  strength, 
every  three  or  four  days,  together  with  peroxide  of  hydrogen 
daily.  The  first  application  of  carbolic  acid  may  be  full 
strength,  followed  by  washings  with  a  five  per  cent,  solution 
of  the  same,  and  peroxide  of  hydrogen  daily. 

Astringents  are  also  valuable.  Sulphate  of  zinc,  five  grains 
to  the  ounce  of  water,  or  chloride  of  zinc,  three  grains,  or  tannic 
or  gallic  acid,  three  grains  to  the  ounce,  may  be  used  daily  or 
alternated  with  the  above-mentioned  disinfectants  and  caustics. 

If  patients  find  it  impracticable  or  very  inconvenient  to  call 
daily  the  disease  may,  in  most  cases,  be  treated  successfully  if 
the  applications  are  made  at  longer  intervals. 


no  OPERATIVE    DENTISTRY. 

NECROSIS  OF  TEETH. 

Necrosis,  as  applied  to  a  tooth,  means  death  of  the  entire, 
organ,  both  pulp  and  pericementum.     It  rarely  occurs. 

It  is  caused  by  dead  pulp,  violence,  long  use  od  mercury, 
calcular  deposit,  exhausting  diseases,  or  impaired  nutrition. 

Sig-ns. — Tooth  much  discolored,  loose,  with  little  or  no 
vascular  connection. 

Trcatinoit. — Removal. 

REPLANTATION  OF  TEETH. 

Replantation  of  teeth  is  a  practicable  operation,  and  a  very 
useful  one  in  cases  of  persistent  chronic  inflammation  or 
abscess,  or  of  accidental  removal. 

To  perform  the  operation,  extract  the  tooth  with  care  and 
wash  it  in  tepid  water,  scrape  off  the  thickened  pericementum 
or  abscess,  and  file  or  cut  off  a  little  from  the  end  of  the  root ; 
enlarge  the  foramen  from  the  outside  with  a  conical  reamer, 
fill  with  gold  and  polish.  If  not  already  treated,  remove  the 
decay  from  the  cavity  and  the  pulp  from  the  pulp  canal,  fill 
the  canal  and  the  cavity  and  finish. 

Syringe  the  socket  clean  with  warm  salt  water,  and  be  sure 
that  all  blood  clots  are  removed  and  that  bleeding  has  ceased. 
Bathe  the  tooth  in  solution  of  bichloride  of  mercury  2iHrd' 
reinsert  in  the  socket  and  carry  firmly  to  place,  allowing  the 
patient  to  bite  firmly  together  to  insure  proper  occlusion. 
Secure  the  tooth  with  silk  ligatures.  If  it  be  an  anterior 
tooth,  tie  the  silk  to  the  necks  of  the  adjoining  teeth,  and 
around  the  replanted  tooth  above  the  cingule. 

If  it  be  a  bicuspid,  tic  a  ligature  around  the  neck  of  each 
of  the  adjoining  teeth  and  over  the  crown  between  the  cusps 
of  the  replanted  tooth. 

The  molar  teeth  can  seldom  be  replanted  with  success. 

The  tooth  may  be  kept  out  of  its  socket  several  hours,  but 
the  shorter  the  time  the  better  will  be  the  chances  of  success. 

Transplantation    of    teeth    may   be   performed  when    two 


ALVEOLAR    AHSCKSS.  Ill 

patients  are  found  at  the  same  time,  one  needing  a  tooth  sup- 
phed,  and  another  healthy  patient  having  a  suitable  tooth 
which  he  is  wiUing  to  sacrifice.  Tlie  same  directions  should 
be  observed  as  in  replantation. 

E.xtracted  teeth  may  also  be  prepared  as  for  replanting,  and 
kept  indefinitely  in  carbolic  acid  water  and  used  as  occasion 
may  require. 

Teeth  have  been  successfully  transplanted  after  remaining 
in  this  solution  several  months. 

Teeth  may  be  transplanted  into  artificial  sockets,  a  hole  of 
proper  size  being  cut  through  the  gum,  and  a  socket  of 
proper  size  and  shape  being  formed  in  the  bone  with  drill  and 
burs  and  the  tooth  inserted  as  in  other  cases.  Many  cases 
have  proved  temporarily  successful,  but  the  value  of  the  opera- 
tion is  by  no  means  established. 

ALVEOLAR  ABSCESS. 

The  term  alveolar,  as  applied  to  abscess,  indicates  its  loca- 
tion within  the  alveolar  walls,  and  with  rare  exception  it  is  at 
the  apex  of  the  root  of  the  tooth. 

Alveolar  abscess  is  either  acute  or  chronic. 

Acute  abscess  is  the  result  of  active  inflammation,  and 
usually  runs  its  course  in  from  three  to  six  days.  As  pus  is 
formed  absorption  of  tissue  takes  place  toward  the  point  ot 
least  resistance.  This  is  called  pointing.  When  pus  is  dis- 
charged the  abscess  may  heal  at  once.  When  acute  abscess 
fails  to  heal,  pus  continues  to  form,  a  fistula  becomes  estab- 
lished and  the  abscess  becomes  chronic. 

Occasionally  acute  abscess  is  cured  spontaneously  by 
resorption  of  the  pus  without  pointing,  or  the  formation  of  a 
sinus. 

Sometimes  the  pus  is  not  absorbed,  but  remains  and  the 
parts  become  tumefied,  forming  what  is  called  cold,  or  blind 
abscess,  which  is  also  chronic.  Alevolar  abscess  usually 
points  through  the  buccal   or  labial  tissue  nearly  opposite  the 


I  I  2  OPERATIVE    DENTISTRY. 

offending  root,  sometimes  through  the  palatal  or  lingual  sur- 
face of  the  jaws,  and  occasionally  into  the  antrum  or  into  the 
nares,  the  discharge  dropping  down  behind  the  palate,  or  on 
the  outer  surface,  as  under  the  chin  or  behind  the  angle  of 
the  jaw.  In  one  case  pus  gravitated  around  the  hyoid  bone, 
causing  glossitis  and  death.  Pus  from  abscess  of  the  superior 
third  molar  may  pass  forward  into  the  frontal  region  and  dis- 
charge from  beneath  the  orbit,  or  at  the  inner  or  the  outer 
canthus,  or,  passing  down  beneath  the  deep  cervical  fascia,  dis- 
charge at  the  nucha,  or  well  down  on  the  scapula.  From  the 
inferior  third  molar  it  may  discharge  low  down  on  the  chest, 
even  to  the  fifth  rib,  following  the  sterno-mastoid  and  pectoral 
muscles.  A  common  channel  for  the  discharge  of  pus  is 
through  the  canal  of  the  root,  and  in  such  cases  the  abscess 
must  be  entirely  cured  before  the  root  is  filled. 

Alveolar  abscess  is  a  sequence  of  pericementitis,  for  the 
causes  of  which  see  page  107. 

The  symptoms  of  acute  abscess  are  extreme  soreness  of 
the  tooth,  chill,  fever,  throbbing  pain,  and  in  the  later  stages 
swelling  and  fluctuation:  The  pain  of  acute  abscess  is  very 
severe  until  the  pus  has  penetrated  the  bone. 

The  principal  sign  of  chronic  abscess  is  the  presence  of  the 
sinus  and  the  discharge  of  pus.  Necrosis  occasionally  results, 
and  the  symptoms '  above  described  assume  an  aggravated 
form. 

Symptoms  of  cold  or  blind  abscess  are  tumefaction  of  its 
parts,  and  characteristic  thinning  of  the  walls,  which  often 
yield  readily  to  pressure  of  the  finger. 

Treatment  of  Alveolar  Abscess. — To  abort  an  abscess.  If 
the  root  of  the  tooth  has  not  been  cleansed  and  filled,  open 
freely  into  the  root  canal,  and  allow  it  to  remain  open  until  the 
pus  or  other  products  of  inflammation  have  passed  off  and  the 
condition  is  relieved. 

Apply  a  capsicum  bag  or  plaster,  or  strong  tincture  of 
iodine,  or  equal  parts  tincture  of  iodine  and  tincture  of  aconite, 
to  the  gum  over  the  affected  parts,  or  saturate  a  piece  of  cotton 


ALVEULAR    ABSCESS,  II3 

with  cliloroform,  place  it  on  the  gum,  cover  with  a  piece  of 
rubber  dam  and  hold  it  in  place  with  the  finger  two  or  three 
minutes.  Bloodletting  will  also  be  of  use,  and  it  may  be 
effected  by  scarification  or  by  leeches.  Give  quinine  and 
Dover's  powder  at  night,  and  a  saline  cathartic,  sufficient  to 
act  quickly,  in  the  morning.  If  pain  becomes  unbearable, 
give  an  opiate. 

If  the  abscess  is  not  cured  in  this  early  stage,  its  pointing 
may  be  hastened  by  continued  application  of  capsicum  bags 
or  plasters,  and  its  course  favorably  modified  by  fomentations 
applied  to  the  face,  and  opiates  to  relieve  severe  pain ;  but  if 
any  tendency  to  point  on  the  outside  of  the  face  is  shown, 
fomentations  should  be  avoided. 

If  the  pulp  canals  have  previously  been  filled,  it  is  in  some 
cases  practicable  to  remove  the  filling  from  the  root,  or  drill 


Fig.  86. 


through  it,  and  thus  gain  relief,  as  before  described;  but  usu- 
ally the  abscess  will  complete  its  course  and  point  upon  the 
gum. 

When  pointing  shows  upon  the  gum,  the  lancet  (Fig.  86) 
should  be  used  to  evacuate  the  pus. 

Oftentimes,  if  the  location  of  the  abscess  can  be  determined, 
relief  may  be  early  obtained  by  drilling  the  alveolar  wall  with 
an  ordinary  drill  in  the  engine  or  the  hand,  first  cutting  the 
gum  with  a  circular  knife  in  the  engine.  The  knife  should  be 
dipped  in  glycerine  or  oil  to  prevent  adhesion  of  the  tissue. 
A  circular  piece  of  the  soft  tissue  being  thus  removed,  imme- 
diate healing  is  prevented  without  further  treatment. 

At  a  subsequent  sitting,  cleanse  and  disinfect  the  root  canals, 
and  stop  lightly  with  cotton  moistened  with  some  disinfectant. 
The  followine:  is  excellent : — 


114  OPERATIVE    DENTISTRY. 

Carbolic  acid  cryst. ^j 

Iodine ^j 

Alcohol '^ij.     M* 

Others  may  be  substituted.  Cover  this  with  cotton  and 
sandarac,  or  gutta-percha  and  wax,  and  allow  it  to  remain  one 
or  two  days ;  then  remove  and  repeat  the  dressing,  and  stop 
with  cotton  as  before,  but  more  tightly.  Repeat  this  treat- 
ment till  the  tooth  will  bear  to  be  stopped  tight.  This  is 
proof  that  the  tooth  is  in  proper  condition  for  filling. 

The  more  simple  forms  of  chronic  abscess  will  be  cured  by 
the  same  course  of  treatment  of  the  root  canals,  especially 
those  which  have  no  fistula  established,  but  are  discharging 
through  the  root  canal. 

Tj'eatinent  of  Chronic  Abscess  with  Fistulous  Opening. — 
Cleanse  and  disinfect  the  root  canals,  and  as  soon  as  they  can 
be  made  thoroughly  dry,  fill  permanently.  This  may  be  at 
the  first  or  at  a  subsequent  sitting.  The  escape  of  moisture 
through  the  foramen  may  render  it  impossible  to  make  the 
root  canals  dry  until  the  abscess  has  partially  healed.  In  the 
meantime,  the  canals  should  be  kept  tightly  filled  with  cotton, 
and  the  opening  covered  with  sandarac  or  gutta-percha.  In 
most  cases  this  treatment  is  sufficient  to  cure  the  abscess. 

If  the  fistula  persists  after  treatment  -for  one  or  two  weeks, 
and  the  root  has  not  been  permanently  stopped,  fill  an  abscess 
syringe,  having  a  long,  fine  point,  with  an  injecting  fluid,  such 
as  carbolic  acid  water,  sulphuric  ether,  peroxide  of  hydrogen, 
or  ten  per  cent,  solution  of  chloride  of  zinc. 

Place  the  point  of  the  syringe  in  the  root  canal,  seal  the 
cavity  with  gutta-percha,  and  inject  the  fluid,  forcing  it,  if 
possible,  through  the  root,  along  the  fistulous  tract,  until  it 
escapes  at  the  opening  on  the  gum.  Refill  the  root  tempo- 
rarily, and  if  at  the  end  of  one  week  the  fistula  is  not  healed, 
repeat  the  treatment,  and  if  after  two  or  three  repetitions,  with 
the  same  interval  between,  the  abscess  is  not  cured,  there  is 

*  Dr.  Litch. 


ALVEOLAR    ABSCESS. 


115 


reason  to  suspect  some  roughness  or  deposit  upon  the  root. 
Fill  the  root  canal  permanently,  then  enlarge  the  fistula  with 
a  sponge  tent  or  by  incision,  or,  if  the  fistula  is  not  direct, 
make  a  new  opening,  for  which  the  circular  knife  and  trephine 
are  excellent.  Remove  any  deposit  or  roughness  from  the 
root,  wash  the  parts  and  leave  the  case  to  heal. 

If  the  discharge  from  an  abscess  is  septic,  strong  antiseptics 
are  needed.  The  whole  abscess  should  be  injected  with  a 
ninety-five  per  cent,  solution  of  carbolic  acid,  strong  tincture 
of  iodine,  or  ethereal  solution  of  iodoform.  Repeat  within 
four  days,  and  follow  with  the  milder  treatment  described 
above.     Such  cases  will  require  considerable  time  to  recover, 


Fic.  87. 


and  constant  care  will  be  requisite  to  keep  the  parts  in  good 
condition. 

If  the  case  is  complicated  by  necrosis,  time  must  be  given 
for  exfoliation,  after  which  the  dead  bone  is  to  be  removed 
and  the  wound  treated  with  mild  applications.  Support  the 
soft  parts  in  place  by  sutures,  if  necessary,  until  healed. 

Intractable  abscess  may  sometimes  be  cured  by  amputation 
and  removal  of  a  part  or  the  whole  of  a  root  of  a  tooth. 

A  hypodermic  syringe,  or  one  specially  designed  for  the 
purpose,  may  be  used.  Fig.  Sy  shows  one  recently  devised 
by  Dr.  Dunn,  which  is  simple  and  effective. 


Il6  OPERATIVE    DENTISTRY, 

EXTRACTING   TEETH. 

The  operation  of  extracting  teeth  requires  skill,  judgment 
and  experience,  and  accurate  anatomical  knowledge  of  the 
parts.  It  is  one  of  the  most  difficult  and  uncertain  operations 
in  surgery. 

The  improved  instruments  of  the  present  time  render  the 
operation  much  less  difficult  and  dangerous  than  formerly. 
The  demand  for  the  operation  does  not  arise  from  fancy, 
fashion  or  caprice,  but  from  dire  necessity,  and  few  escape  it. 

Examine  the  mouth  carefully,  to  be  sure  which  is  the 
offending  tooth.  The  patient's  knowledge  and  judgment  must 
not  be  depended  upon,  as  the  pain  may  be  referred  to  a  distant 
tooth,  even  in  the  opposite  jaw. 

Some  conditions  may  forbid  extraction,  as  heart  disease  so 
far  advanced  that  the  shock  might  prove  fatal,  a  pronounced 
hemorrhagic  diathesis,  or  active  constitutional  syphilis.  Preg- 
nancy does  not  forbid. 

The  operation  should  not  be  hurried.  Move  no  faster  than 
the  eye  can  carefully  follow,  and  the  mind  fully  comprehend, 
each  movement  of  hand  and  instrument.  With  care  a  g-reat 
amount  of  force  may  be  applied  safely,  but  a  small  force 
unskillfully  applied  may  do  injury,  especially  by  breaking  the 
tooth  or  bruising  and  lacerating  the  gum.  The  amount  of 
force  required  can  be  only  roughly  estimated  before  the 
operation.  The  operator  must  feel  his  way,  and  apply  force 
in  amount  and  direction  as  it  is  needed. 

Characteristics  of  teeth  which  are  difficult  to  extract: — 

1.  Those  with  short,  thick  crowns. 

2.  Incisors  that  occlude  and  are  thick  and  strong. 

3.  Teeth  which  are  particularly  regular  and  in  close  contact 
indicate  conditions  which  render  extraction  difficult. 

4.  Teeth  with  small  necks  and  long  roots  in  dense  alveolar 
walls. 

5.  Teeth  affected  with  hypercementosis. 

6.  The  upper  cuspids  are  uniformly  hard  to  extract. 


EXTKACTINii    TKF.TH. 


117 


Conditions  which  render  extraction  peculiarly  painful 
are  liypera^sthesia  of  the  parts,  neuralgia  of  the  fifth  nerve 
inflammation  of  the  surrounding  tissues. 

Indications  for  Extraction. 

1.  Persistent  abscess,  hypercementosis,  or  other  painful  or 
diseased  conditions  that  cannot  be  otherwise  cured. 

2.  When  needed  to  prevent  or  correct  irregularity. 

3.  When  the  temporary  obstruct  the  eruption  of  the  per- 
manent teeth  ;  but  do  not  remove  adjoining  teeth  simply  to 
give  room. 

4.  Temporary  teeth  may  need  to  be  removed  early  to  relieve 
irritation  or  inflammation. 

5.  Need  of  preparing  the  mouth  for  artificial  denture. 
Since  the  forceps  have  become  so  much  improved  in  the 

form,  size    and    adaptability    of  the    beaks    gum-lancing    has 


Fig.  88. 


fallen  into  disuse,  and  at  present  few  operators  advise  it.  Oc- 
casionally the  operation  may  be  of  service  to  prevent  lacera- 
tion of  the  thick  and  adherent  gum  around  a  tooth  standing 
alone.  A  form  of  lancet  well  adapted  to  the  purpose  is  shown 
in  Fig.  88.  Carry  the  lancet  down  to  the  alveolus  and  pass  it 
around  the  tooth,  severing  as  completely  as  possible  the  adher- 
ent gum. 

In  the  case  of  roots  where  it  is  necessary  to  grasp  and  cut 
through  a  portion  of  the  alveolar  process,  an  incision  may  be 
made  in  a  line  with  the  axis  of  the  tooth  and  the  gum  freed 
from  the  alveolus  each  way  from  the  line.  This  may  be  done 
with  two  downward  strokes  of  the  lancet. 

The  number  of  teeth  that  may  be  extracted  at  one  sitting 
varies  greatly,  according  to  the  mental  and  physical  condition 


I  I  8  OPERATIVE    DENTISTRY. 

of  the  patient.  In  favorable  conditions  fifteen,  twenty  or  even 
more  teeth  may  be  removed  without  untoward  results,  while 
in  cases  of  extreme  fear  or  other  mental  disturbance,  or  of  physi- 
cal debility,  one  may  be  all  that  it  will  be  prudent  to  extract 
at  one  sitting.  A  tendency  to  epilepsy  may  render  a  patient 
less  able  to  bear  the  shock  of  the  operation. 

Pregnancy  should  be  considered,  and  no  more  should  be 
done  than  is  necessary  to  give  relief 

In  great  debility,  stimulants  may  be  given  before  the  opera- 
tion. In  mental  irritability,  sedatives  may  serve  a  better  pur- 
pose. 

It  should  be  remembered  that  the  sensitiveness  of  the  fifth 
nerve  is  such  that  injury  to  any  of  its  branches  has  a  pecu- 
liarly depressing  effect  upon  the  heart's  action. 

Accidents. 

1.  Breaking  teeth. 

2.  Fracture  of  alveolus. 

3.  Laceration  of  gum. 

4.  Removal  of  wrong  tooth. 

5.  Dislocation  of  inferior  maxilla. 

6.  Hemorrhage. 

7.  Syncope. 

8.  Dropping  of  the  extracted  tooth  into  the  patient's  throat. 

9.  Gangrene  of  the  socket. 

The  fracture  of  teeth  and  alveolus  can,  in  most  instances, 
be  avoided  by  the  exercise  of  proper  care  and  skill,  though 
sometimes  the  resistance  of  the  alveolar  walls  embracing 
divergent  or  malformed  roots  renders  the  removal  of  the  tooth 
without  fracture  impossible.  The  breaking  of  a  tooth  often 
proves  to  be  a  serious  accident.  Severe  inflammation  and 
great  suffering  follow. 

If  a  tooth  is  fractured  and  the  removal  of  the  remaining  por- 
tion is  impracticable  or  unadvisable  owing  to  the  injury  that 
would  necessarily  be  inflicted  in  its  removal,  and  the  pulp 
remains  exposed,  pain  may  be  allayed  by  the  use  of  creasote, 
after  which  it  may  be  devitalized  by  the  application  of  arsenical 


EXTRACTING    TKETH.  I  I9 

paste.  This  ma}'  be  readily  held  in  jjosition  by  a  loose  pellet 
of  cotton  saturated  with  sandarac,  the  latter  forming  a  cap 
which  stays  firmly  in  place. 

Laceration  of  the  gum  is  likely  to  occur  only  when  undue 
haste  is  e.xercised,  hence,  due  deliberation  and  care  will  pre- 
vent it.  If,  during  the  operation,  the  gum  is  found  to  adhere 
to  the  tooth,  stop  the  operation  and  sever  it  with  lancet  or 
scissors,  and  then  complete  the  extraction. 

The  removal  of  a  wrong  tooth  is  inexcusable  under  all  cir- 
cumstances, and  is  wholly  due  to  carelessness  in  applying  the 
instrument,  or  lack  of  observation  in  examination. 

Dislocation  of  the  jaw  is  caused  by  spasmodic  action  of 
the  depressor  muscles,  and  may  be  prevented  by  properly 
supporting  the  jaw  with  the  left  hand  during  the  opera- 
tion. If  this  does  occur,  the  dislocation  may  be  reduced 
by  standing  in  front  of  the  patient,  placing  the  thumbs 
upon  the  molar  teeth  of  each  side  of  the  jaw  and  pressing 
downward  and  backward,  at  the  same  time  elevating  the 
chin  with  the  fingers  underneath.  The  operator  must  be 
ready  to  slip  the  thumbs  outward,  off  the  teeth,  lest  they 
be  caught  by  the  sudden  closing  of  the  jaw  when  it  goes 
to  place. 

Syncope. — Fainting  may  occur  during  or  subsequent  to 
the  operation.  It  usually  results  from  terror,  rarely  from  loss 
of  blood.  A  dose  of  some  stimulant  given  before  the  opera- 
tion may  prevent  it.  The  best  remedies  are  a  horizontal  or 
reclining  position  and  plenty  of  air.  A  little  cold  water 
sprinkled  on  the  face  will  hasten  recovery. 

Hemorrhage. — Arterial  hemorrhage  takes  place  from  the 
severed  dental  arteries.  Capillary  hemorrhage  is  seen  in  the 
oozing  of  blood  from  the  wounded  surfaces  of  the  gum. 

Hemorrhage  may  be  primary  or  secondary.  Primary  hem- 
orrhage is  that  which  immediately  follows  the  operation. 

Secondary  hemorrhage  takes  place  a  few  days  after  the 
operation  and  is  the  result  of  sloughing  of  the  clot. 

Arterial  hemorrhage  may  be  readily  controlled  by  packing 


120  OPERATIVE    DENTISTRY. 

the  socket  with  cotton,  dry  or  soaked  in  solution  of  alum, 
tannin  or  persulphate  of  iron. 

To  stop  capillary  hemorrhage,  plug  the  socket,  as  before, 
filling  it  completely  so  as  to  press  upon  the  wounded  edges  of 
the  gum.  Usually  this  will  succeed.  If  the  bleeding  still 
persists,  it  may  be  necessary  to  bring  pressure  upon  the  sur- 
face, as  by  placing  cotton  dipped  in  solution  of  persulphate  of 
iron  or  other  styptic  upon  the  gum  and  maintaining  pressure 
with  the  fingers,  or  by  gutta-percha  or  modeling  composition 
warmed  and  molded  to  the  part,  or  plaster  sufficient  in  quan- 
tity to  meet  the  occlusion  of  the  opposite  teeth  or  jaw. 

The  pressure  should  be  moderately  firm  and  steady  and 
continued  for  some  hours,  until  danger  of  a  return  of  the 
bleeding  is  past.  The  cotton  should  be  allowed  to  remain 
until  expelled  by  the  healing  process.  The  treatment  for 
primary  and  secondary  hemorrhage  is  the  same. 

If  the  persulphate  of  iron  in  powder  be  applied  to  the  bleed- 
ing surface  and  a  pledget  of  cotton  large  enough  to  cover  be 
held  down  firmly  for  ten  or  fifteen  minutes,  the  cotton  will 
remain  adherent  to  the  surface  and  effectually  stop  the  bleed- 
ing in  nearly  every  case. 

Hot  water  is  an  excellent  styptic. 

Rest  is  all-important  in  the  treatment  of  hemorrhage. 

The  actual  cautery  is  a  last  resort  and  it  will  succeed  when 
all  else  fails.  The  cautery  should  be  of  suitable  size,  not  too 
large,  heated  not  quite  to  redness,  and  held  close  to  the  bleed- 
ing surface,  but  not  allowed  to  touch  it,  as  the  tissue  would 
stick  to  the  instrument  and  be  torn  away. 

Gangrene  of  the  socket  results  from  degeneration  and  putre- 
faction of  the  clot  formed  after  extraction.  Granulation  does 
not  take  place,  pain  and  tenderness  continue  and  the  clot 
sloughs  out  leaving  the  bony  walls  of  the  socket  exposed, 
putrescent  and  offensive. 

A  low  or  depressed  condition  of  the  system  tends  to  pro- 
duce this  result. 

For  treatment,  cleanse  the  parts  carefully  with  warm  water,. 


INSTKUMIiNTS.  121 

addin;^  tlic  solution  of  chlorinated  soda  as  a  disinfectant, 
and  then  apply  pure  deliquesced  carbolic  acid.  This  is  thought 
by  some  to  be  a  specific.  One  application  is  usually  sufficient. 
Sulphurous  acid  is  used  successively,  and  nitric  acid  carefully 
applied  will  promote  a  healthy  action. 


INSTRUMENTS. 

For  extraction  of  the  teeth  the  following  instruments  will  be 
necessary,  viz. :  one  upper  molar  forceps  for  either  side,  Fig.  89, 
one  lower  molar  for  either  side.  Fig.  90,  one  for  upper  bicus- 
pids, cuspids,  incisors  and  roots.  Fig.  91,  one  for  lower 
bicuspids,  cuspids  and  incisors,  Fig.  92,  making  four  pairs. 
This  seems  to  be  the  least  number  that  will  answer  the 
purpose. 

The  set  will  be  more  complete  with  the  following  added, 
viz.  :  upper  cowhorn,  right  and  left,  Figs.  93  "and  94,  lower 
molar  cowhorn  for  either  side.  Fig.  95,  Physic's  forceps  for  lower 
third  molars.  Fig.  96,  making  eight  pairs.  To  these  may  be 
added  the  key  of  Garengeot,  a  desirable  form  of  which  is 
shown  in  Fig.  97.  The  styles  and  forms  of  forceps  manu- 
factured are  very  numerous.  A  few  more  desirable  forms 
will  be  added :  one  universal  spicular  root.  Fig.  98,  one 
extra  narrow  beak  for  crowded  teeth.  Fig.  99,  and  one  pair 
alveolar  forceps  for  upper.  Fig.  100,  and  one  for  lower, 
roots.  Fig.  1 01. 

Many  practitioners  will  desire  peculiar  patterns,  which  they 
can  select  or  have  made  to  order,  but  it  is  well  for  young 
practitioners  to  remember  that  skill  in  the  use  of  difciv  instru- 
ments is  better  than  the  possession  of  many. 

The  forceps  should  be  strong  in  all  their  parts,  but  not 
clumsy.  The  handles  should  be  thick  enough  to  prevent 
springing  under  the  grasp  of  the  hand. 

Forceps  should  be  selected  of  such  shape  and  size  that  they 
will  conform  to  the  hand  that  is  to  use  them. 
9 


Fig.  89. 


Molar,  upper.     Either  side. 
122 


Fig.  90. 


Fig.  91. 


Molar,  lower.    Either  side. 


Root,  upper.     Bayonet  shape. 


123 


Fig.  92 


Bicuspids,  cuspids  and  incisors,  lower.     Hawkbill. 
124 


Molar,  upper.     Right  side.     Cowhorn. 
125 


Fig.  94- 


Molar,  upper.     Left  side.     Cowhorn. 
126 


Fig.  95. 


Fif.    96. 


Molar,  lower.     Either  side.     Cowhorn.  Denies  Sapientiae,  lower.     Either  side. 

127 


Fig.  97. 


128 


Fir. 


Fig.  99. 


ROOT,  UFIKK.      IIAYUNF.T   SHAPE. 
SLENDER   BEAKS. 

For  difficult  roots  in  upper  jaw, 
and  roots  of  front  teeth  in  lower 
jaw.  Designed  by  Dr.  B.  F. 
Arrington. 


Incisor,  lower.     Hawkbill. 
(Crowded  teeth.) 


129 


Alveolar.     Bayonet  shape.     Small. 
130 


Fig.  loi. 


Alveolar,  lower.     Either  side.     Designed  by  Dr.  Parmly. 


132  OPERATIVE    DENTISTRY. 

Position  of  Patient  and  Operator. — For  extracting,  a  chair 
the  height  of  an  ordinary  easy  chair  is  best.  It  should  be  firm 
and  strong,  with  an  ample  head-rest,  and  somewhat  inclined 
backward. 

To  extract  the  left  upper  bicuspids  and  molars,  the  operator 
should  stand  at  the  right  and  a  little  in  front  of  the  patient. 
Place  the  little  finger  and  ulnar  side  of  the  left  hand  across 
the  forehead;  with  the  forefinger  in  the  mouth  distend  the 
cheek,  and  with  the  thumb  depress  the  lower  lip.  This  will 
expose  the  teeth  fully  to  view.  Apply  the  forceps  and  extract 
as  directed. 

To  extract  the  right  upper  bicuspids  and  molars,  stand  at 
the  right  of  the  patient ;  place  the  ulnar  portion  of  the  palm 
of  the  left  hand  upon  the  right  side  of  the  forehead,  and  with 
the  forefinger  distend  the  cheek  opposite  the  teeth ;  with  the 
second  finger  depress  the  lower  lip,  apply  the  forceps  as 
directed  and  extract  the  tooth. 

To  extract  the  six  anterior  teeth  of  the  upper  jaw,  stand  at 
the  right,  and  with  the  left  hand  hold  the  patient's  head  firmly 
against  the  side.  With  the  forefinger  elevate  the  upper  lip, 
and  with  the  second  guard  the  lower.  This  will  expose  the 
teeth  and  the  instrument  may  be  readily  applied. 

To  extract  the  lower  molars  and  bicuspids  of  the  right 
side,  stand  directly  behind  the  patient,  support  the  chin  in  the 
palm  of  the  left  hand,  with  the  forefinger  distend  the  cheek, 
and  with  the  thumb  depress  the  tongue.  Apply  the  forceps 
and  extract. 

To  extract  the  left  lower  molars  and  bicuspids,  still  standing 
behind  the  patient,  place  the  palm  of  the  hand  against  the  side 
of  the  face,  supporting  the  lower  jaw  with  the  third  and  fourth 
fingers,  distend  the  cheek  with  the  first  finger,  and  depress 
the  lower  lip  with  the  second,  when  the  teeth  may  be  clearly 
.seen  and  the  forceps  applied.  The  left  lower  bicuspids  may 
often  be  successfully  extracted  with  the  operator  facing  the 
patient. 

To    extract  the  lower  incisors  and  cuspids,  stand   at   the 


POSITION    OF    PATIENT    AND    OPERATOR.  1 33 

• 

rii^ht,  pass  the  left  hand  under  the  patient's  chin,  support  the 
lower  jaw  with  the  finj^ers,  depress  the  lower  lip  with  the 
forefinger,  and  the  tongue  with  the  thumb. 

To  extract  the  right  lower  bicuspids  with  the  key,  stand 
in  front  and  facing  the  patient.  For  applying  the  key  in  all 
other  cases,  stand  somewhat  behind  the  patient,  with  the  first 
and  second  fingers  distend  the  lips  and  cheek  and  apply  the 
instrument,  guiding  the  hook  with  the  finger. 

To  extract  a  tooth  with  the  forceps,  pass  the  beaks  well 
under  the  gum,  against  the  border  of  the  alveolus,  and  grasp 
the  tooth  firmly ;  then  make  moderate  traction,  together  with 
an  outward  and  inward  movement,  mostly  outward,  until  its 
connection  with  the  jaw  is  broken,  w^hen  it  may  be  removed. 
Avoid  grasping  the  teeth  too  hard,  as  excessive  pressure  is 
liable  to  break  them. 

In  mar\^  operations  we  are  more  successful  by  applying  a 
pushing  force  combined  w^ith  other  movements  until  the  tooth 
is  loosened.  This  is  applicable  to  the  upper  incisors,  and 
especially  to  the  bicuspids.  In  extracting  the  upper  central 
incisors,  a  rotating  movement  is  especially  applicable.  Traction 
should  seldom  be  made  until  the  tooth  is  loosened. 

In  the  case  of  the  cuspids,  the  outward  movement  must  be 
mainly  depended  upon,  as  the  flattened  form  of  the  root 
renders  rotation  impossible.  The  greater  size  and  length  of 
the  roots  of  these  teeth,  together  with  the  flattened  form,  make 
them  much  more  difficult  to  extract  than  either  the  incisors 
or  bicuspids.  It  is  sometimes  necessary  to  pass  the  beak  of 
the  forceps  well  up  on  the  alveolus  and  cut  it  through  before 
the  tooth  can  be  made  to  yield. 

In  extraction  of  the  upper  bicuspids,  press  the  forceps  hard 
up  against  the  alveolus,  at  the  same  time  moving  the  hand 
outward  and  inward  till  the  tooth  gives  way,  when  it  may  be 
removed  by  a  direct  pull. 

In  extracting  the  first  and  second  upper  molars,  the  same 
directions  are  applicable  as  for  the  bicuspids,  whether  the 
plain  or  cowhorn  forceps  is  used.     The  use  of  the  cowhorn 


134  OPERATIVE    DENTISTRY. 

* 

forceps  necessitates  a  less  amount  of  force  than  the  plain 
beak,  as  the  cowhorn  weakens  the  alveolar  wall  by  breaking 
down  its  edge,  and  by  passing  into  the  bifurcation  of  the 
buccal  roots  acts  as  a  wedge,  thus  aiding  in  the  removal. 

The  upper  third  molar  will  almost  invariably  yield  to  a 
simple  outward  movement. 

The  lower  incisors  offer  no  special  difficulties  in  extracting. 
The  outward  and  inward  movement  will  loosen  them,  and  they 
may  be  readily  removed. 

In  extracting  the  lower  cuspids  both  the  lateral  and  rotary 
movements  may  be  used,  and  as  the  roots  are  both  large  and 
long,  the  operation  must  be  deliberately  performed  to  give  time 
for  the  parts  to  yield. 

The  same  directions  are  applicable  to  the  lower  bicuspids,  but 
the  roots  being  shorter  and  nearly  round  renders  their  removal 
somewhat  less  difficult.  , 

The  first  and  second  lower  molars  may  be  extracted  with  the 
plain-beaked  or  the  cowhorn  forceps,  but  to  these  the  latter  is 
particularly  applicable,  as  the  cowhorns  passing  in  at  the  bi- 
furcation of  the  roots  act  as  Avedges,  and  frequently  the  simple 
closing  of  the  beaks  will  lift  the  tooth  from  its  socket. 

When  the  roots  of  the  lower  third  molar  curve  backward, 
forming  a  hook  under  the  ramus  of  the  jaw,  as  is  often  the 
case,  it  is  impossible  to  remove  them  by  direct  force  as  applied 
to  the  first  and  second  molars.  To  meet  this  condition  the 
Physick  forceps  (Fig.  96,  p.  127)  was  constructed.  This  is  used 
by  closing  the  wedge-shaped  beaks  between  the  third  and 
second  molars,  then,  using  the  second  molar  as  a  fulcrum,  the 
handles  are  depressed  and  the  tooth  started  from  its  socket 
{is  unhooked).  Ifthe  tooth  be  then  grasped  with  the  double 
cowhorn  forceps  it  may  be  easily  removed,  as  the  points  of 
the  beaks  act  as  pivots  on  which  the  tooth  may  turn  and  follow 
in  its  removal  the  natural  curve  of  the  root.  In  this  manner 
teeth  may  be  removed  without  difficulty  whose  roots  form 
perfect  hooks,  which  it  would  be  impossible  to  remove  by  any 
other  method.     In  most  cases  the  lower  third  molar  may  be 


1CXTKACT1N(;    ROOTS.  1 35 

easily  extracted  with  tlie  elevator  by  passint^  the  beak  down 
on  the  mesio-buccal  angle  between  the  root  and  the  ah'colar 
wall,  and  l)r>'ing  it  out. 


EXTRACTING  ROOTS. 

Decidedly  the  best  instrument  for  extracting  roots  is  the 
universal  spicular  root  forceps,  Fig.  98,  p.  129.  The  beaks, 
being  narrow  and  sharp,  pass  easily  beneath  the  gum  and 
effectually  seize  the  root,  rendering  the  use  of  the  gum  lancet 
unnecessary.  The  forceps  should  be  pressed  upward  with  a 
rotating  motion  till  the  connection  between  the  root  and  the 
jaw  is  entirely  broken. 

In  the  case  of  recently-fractured  teeth  it  may  be  necessary 
to  cut  through  the  alveolus,  for  which  purpose  this  same  for- 
ceps may  be  used  for  the  ten  anterior  teeth,  or  the  alveolar 
forceps,  Fig.  100,  p.  130,  for  the  upper  jaw,  and  Fig.  loi,  p. 
131,  for  the  lower. 

Roots  of  upper  molars,  when  firm  in  the  jaw,  may  be  best 
removed  with  the  cowhorn  forceps,  placing  the  inner  beak 
over  the  palatal  root  so  as  to  get  a  firm  support,  and  the  cow- 
horn  placed  immediately  over  one  of  the  buccal  roots,  clos- 
ing the  instrument  the  cowhorn  will  pierce  the  alveolus  and 
impinging  upon  the  root  will  easily  start  it  from  its  socket. 
Without  removing  the  instrument  open  the  beaks  and  repeat 
the  operation  on  the  other  buccal  root.  Remove  the  instru- 
ment from  the  mouth,  and  with  the  spicular  forceps  remove 
the  loosened  buccal  roots  and  extract  the  palatal  root. 

In  case  of  necessity  the  inner  beak  may  be  placed  far 
up  on  the  palatal  surface  of  the  gum,  and  the  cowhorn 
used  as  before  described.  The  instrument  being  carefully 
removed  leaves  only  a  simple  wound  of  the  gum,  which 
readily  heals. 

Roots  of  lower  molars  may  generally  be  successfully  re- 
moved with  the  lower  cowhorn,  Fig.  95,  p.  127.  Place  the 
inner  horn  of  the  instrument  on  the  gum,  well  down  over  the 


136 


OPERATIVE    DENTISTRY. 


alveolus,  then  use  the  outer  horn  upon  the  root,  as  described 
for  the  use  of  the  cowhorn  on  the  upper  molar  roots. 

The  alveolar  forceps  may  also  be  successfully  used  for 
removing  these  roots. 

Special  directions  for  extraction  of  the  tempoi^ary  teeth 
need  not  be  given,  as  they  offer  no  peculiar  difficulties,  but 
caution  should  be  exercised  not  to  injure  the  succeeding  per- 
manent teeth. 

The  English  forceps  *  are  much  smaller  than  the  American 
make.  They  are  strong,  and  peculiarly  well  adapted  to  the 
purpose  for  which  they  are  made.  The  following  figures 
show  some  of  the  more  important  and  characteristic  forms — 

Fig.  102. 


Upper  Incisors  and  Cuspids.  ^ 


Fig.  103. 


Lower  Incisors  and  Cuspids. 


*  The  cuts  of  these  were  furnished  by  Claudius  Ash  &  Sons,  London. 


EXTRACTING    ROOTS. 
Fig.  104. 


137 


Upper  Bicuspids.     Either  Side. 
Fig.  105. 


Lower  Bicuspids 
Fig.  106. 


Upper  Molar.     Right  Side. 
Fig.  107. 


Upper  Molar.     Left  Side. 


138 


OPERATIVE    DENTISTRY. 
Fig.  io8. 


Upper  Third  Molar.     Either  Side. 


Fig.  ic 


Lower  Molar.     Either  Side. 


Fig.  iio. 


Upper  Root. 


ELEVATOR.  1 39 

Fit..  Ill, 


Lower  Root. 


ELEVATOR. 


An  elevator  is  sometimes  very  useful  for  the  removal  of 
roots  of  teeth,  but  since  so  great  improvement  has  been  made 
in  the  construction  of  forceps  it  is  not  so  much  used  as  for- 
merly. The  Cooledge  elevator  with  two  blades,  formed  like 
Fig.  112,  is  of  universal  application,  and  will  serve  all  pur- 
poses for  which  an  elevator  may  be  required.  The  elevator 
is  used  by  passing  the  blade  down  by  the  side  of  the  tooth, 
using  the  edge  of  the  alveolar  process  as  a  fulcrum  for  prying 
it  out.  Sometimes  the  adjacent  tooth  may  be  used  as  the 
fulcrum. 

The  Key. — Since  the  perfection  of  the  forceps,  the  key  has 
fallen  into  disuse,  and  it  i;?  severely  criticised  and  condemned 
by  most  of  the  profession.  A  few  operators  have  continued 
to  use  it,  and  find  in  it  such  merit  that  a  description  of  its  use 
is  with  propriety  included  in  this  chapter,  and  each  teacher 
and  practitioner  will  judge  it  on  its  merits. 

This  instrument,  used  with  skill,  extracts  many  teeth  with 
great  ease  for  the  operator  and  little  pain  for  the  patient.  It 
is  especially  adapted  for  the  removal  of  the  eight  bicuspid 
teeth  and  roots.  The  fulcrum  should  be  round,  about  three- 
fourths  of  an  inch  in  length  from  centre  of  shaft  and  one-lialf 
inch  in  thickness.  The  hook  must  be  long  enough  to  reach 
well  down  on  the  outside  of  the  jaw,  and  well  curved  so  as  not 


I40 


OPERATIVE    DENTISTRY. 


to  be  thrown  off  by  contact  with  the  crown  of  the  tooth  when 
force  is  appHed  to  extract  it.      The  hook  should  have  but  one 


Fig    112. 


Fig.  T13. 


Fig.  114. 


point,  sharp  and  well  tempered,  shown  in 
Fig.  113.  Pad  the  bulb  with  wet  cotton, 
tied  on,  or  a  small  napkin  wound  around  it 
— a  permanent  pad  becomes  foul.  Fig.  114 
shows  the  fulcrum  and  hook  properly  con- 
structed. 

Place  the  fulcrum  on  the  inside  of  the 
jaw  opposite  the  tooth  to  be  extracted,  and 
rest  it  on  the  edge  of  the  gum  well  up  on 
the  neck  of  the  tooth.  If  placed  down  on 
the  gum  the  force  is  exerted  too  much 
laterally,  and  fracture  of  the  tooth  is  likely 
to  result.  If  the  topth  be  strong,  place  the 
point  of  the  hook  on  the  neck  at  the  buccal 
side  of  the  tooth,  pressing  down  the  gum 
a  little,  but  not  sufficient  to  wound  it. 
When  adjusted,  as  in  Fig.  115,  rotate  the 
shaft  inward  gently  until  you  feel  that  the 
hook  is  fixed,  when  a  quick,  resolute  turn 
of  the  hand  will  extract  the  tooth  instantly, 
and  in  almost  every  case  to  the  great 
surprise  of  the  patient  that  it  hurt  so  little. 

The  natural  inclination  inward  of  the 
bicuspids  (see  Fig.    115),   the   taper  of  the 


THE    Ki:V. 


141 


root  toward  the  apex,  the  extreme  thinness  of  the  outer  wall 
of  bone,  and  the  substantial  thickness  of  the  inner  plate, 
render  the  direction  of  the  force  exerted  b\-  the  key  extremely 
favorable. 

If  the  crown  be  gone  below  the  margin  of  tiiegum,  the  ful- 
crum must  be  placed  a  little  further  down  on  the  jaw,  and  the 
hook  placed  well  down  on  the  gum,  even  one-third  of  an  inch 
from  the  margin,  as  in  Fig.  116.  Then  apply  force  as  before, 
and  the  hook  will  penetrate  the  gum  and  alveolar  wall,  catch 
the  root  and  remove  it  with  great  facility,  making  a  clean  cut 


Fic:.  115. 


Fig.  116. 


S,   SHAFT  OF  KEY.    P, — PAD. 
A,  ALVEOLAR  WALL.    J,  JAW. 


P,  PAD. 

A,  ALVEOLAR  WALL. 


through  to  the  edge  without  lacerating  the  gum  or  fracturing 
the  bone.  If  properly  used,  the  fulcrum  will  not  bruise  the 
gum  at  all. 

Some  operators  strenuously  advocate  its  use  for  extraction 
of  the  molars,  especially  of  the  lower  jaw.  In  these  cases  the 
fulcrum  may  be  placed  either  on  the  lingual  or  buccal  side  of 
the  tooth,  preferably  the  latter,  as  the  force  thus  applied  acts 
more  in  accordance  with  the  anatomical  construction  of  the 
parts. 


142  OPERATIVE    DENTISTRY. 

As  forceps  are  numbered  by  the  hundreds,  it  is  impossible 
and  undesirable  to  describe  them  all  in  this  work.  When  the 
operator  shall  have  learned  Avell  to  use  those  already  men- 
tioned, he  will  then  be  able  to  select  such  additional  instru- 
ments as  shall  suit  his  individual  taste. 


AN.^^STHESIA. 

AncBStliesia  is  a  state  of  insensibility,  induced  by  any 
means  or  conditions  whatever.  As  used  in  dental  practice, 
it  means  a  state  of  insensibility  induced  at  the  will  of  the 
operator  by  the  administration  of  medicinal  agents,  usually 
by  inhalation. 

Ether,  nitrous  oxide  gas  and  chloroform  are  the  only  agents 
in  general  use  for  this  purpose.  Their  effect  is  produced  by 
their  action  upon  the  brain,  the  parts  of  which  are  affected  in 
the  following  order : — 

First.     The  cerebrum,  benumbing  sensation  and  volition. 

Second.     The  cerebellum,  affecting  the  coordinating  power. 

Third.  The  medidla  oblongata,  depressing  the  powers  of 
organic  life,  viz.,  circulation  and  respiration. 

Anaesthesia  may  be  divided  into  three  stages,  although  no 
marked  line  of  division  appears  : — 

First.  Stimulation.  The  patient  is  more  quiet,  the  pulse 
is  stronger  and  beats  more  regularly. 

Second.  Excitement.  Consciousness  begins  to  be  lost,  the 
pulse  is  quickened,  the  face  flushes,  the  patient  is  easily 
frightened,  sounds  are  exaggerated,  muscular  movements  are 
irregular  and  often  violent,  owing  to  loss  of  coordinating 
power,  and  soon  become  spasmodic.  The  amount  and  dura- 
tion of  the  excitement  depend  largely  upon  the  mental  condi- 
tion of  the  subject  when  commencing  to  inhale,  and  upon  the 
degree  of  mental  control  exercised  by  the  operator,  and  the 
quiet  and  order  around. 

Third.  Profo2ind  insensibility.  The  muscular  system 
becomes   relaxed,  the  skin  is   insensible,  the   eyelids  do   not 


AN.KSTHKSIA.  1 43 

respond  if  the  lashes  be  touched,  the  conjunctiva  is  insensible 
to  touch  of  the  finger,  the  \n\p'i\  is  dilated.  Still  more  pro- 
found insensibilit)-  is  indicated  by  relaxation  of  the  sphincter 
muscles,  the  sphincter  ani  being  the  last  to  succumb,  by 
stertorous  breathing,  slowing  and  weakening  of  the  pulse, 
shallow  breathing  and  profuse  sweating. 

In  typical  anaesthesia  as  produced  by  ether,  especially  when 
rapidly  inhaled,  sensibility  to  minor  operations  is  entirely  lost 
before  other  powers  are  sensibly  affected,  and  at  this  point  a 
single  tooth  may  be  extracted,  or  a  single  incision  made,  without 
any  pain  being  felt,  although  the  patient  may  be  quite  conscious 
of  all  that  is  being  done.  This  condition  is  indicated  by 
insensibility  to  pinching  of  the  skin,  and  by  the  dropping  of 
the  hand,  which  was  voluntarily  held  up  by  the  patient  at  the 
beginning  of  the  inhalation.  Next  consciousness  is  overcome, 
and  by  this  time  the  coordinating  power  is  considerably 
diminished  and  very  soon  lost,  and  loss  of  all  muscular  power 
quickly  follows. 

This  stage  may  be  maintained  for  a  long  time  without  the 
circulation  or  respiration  being  sensibly  lessened,  and  severe 
and  prolonged  operations  performed.  If  anaesthesia  be  pressed 
further,  the  pulse,  which  at  first  is  full,  strong  and  quick, 
becomes  weak  and  less  frequent,  and  the  respiration  more 
shallow,  showing  that  the  medulla  is  affected. 

Auctsthesia  that  is  produced  quickly  passes  off  quickly.  It 
is  quite  practicable  to  induce  anaesthesia,  perform  an  operation 
and  have  the  patient  recover,  without  apparently  affecting  the 
medulla  at  all,  consequently  no  nausea  follows. 

It  is  prolonged  anaesthesia  that  produces  nausea.  The 
medulla  seems  to  be  affected  in  proportion  to  the  length  of  time 
that  the  agent  is  inhaled. 

Nitrous  Oxide. — Relaxation  of  the  muscles  is  not  constant 
nor  common  in  anaesthesia  produced  by  nitrous  oxide  gas. 
Contraction  instead  of  relaxation  is  likely  to  follow,  and  a 
spasmodic  twitching  of  the  muscles  takes  place,  an  interrupted, 
jcrk\-  inspiration,  and  a  turning  inward  of  the  thumbs  toward 


144  OPERATIVE    DENTISTRY, 

the  palm  of  the  hand.  Beyond  these  indications  it  is  not  safe 
to  affect  the  patient. 

Nitrous  oxide  gas  is  the  agent  par  excellence  for  the  dentist's 
use.  It  is  a  stimulant  to  the  heart,  and  is  as  safe  as  anything 
producing  such  results  can  be.  Deaths  reported  do  not  ex- 
ceed one  in  one  hundred  thousand  administrations,  and  in  all 
fatal  cases  reported  the  cause  of  death  has  been  somewhat  in 
doubt. 

If  the  gas  is  pure,  unpleasant  results  seldom  follow  its  use. 
It  is  nearly  odorless,  so  is  not  unpleasant  to  have  about  the 
office ;  it  is  non-irritating,  hence  not  disagreeable  for  the  patient 
to  breathe  ;  it  acts  quickly,  produces  a  profound  narcosis  and 
passes  off  very  rapidly,  leaving  the  patient  with  a  clear  head 
and  full  pulse,  ready  to  go  on  his  way  by  the  time  the  blood 
is  sufficiently  staunched  to  permit  it. 

If  impure,  as  gas  manufactured  in  a  dental  office  is  likely  to 
be,  unpleasant  effects,  such  as  nausea,  dizziness,  lassitude  and 
headache,  may  follow  and  persist  for  several  days  or  weeks. 

When  administering  the  gas  the  supply  should  be  abundant 
and  free.  All  air  must  be  excluded,  as  a  very  small  per  cent, 
mixed  with  the  gas  will  prevent  its  narcotic  effects 

An  inhaler  with  a  rubber  face-piece  covering  the  mouth  and 
nose,  and  a  double-acting  valve  is  much  to  be  preferred. 

Apply  the  inhaler  to  the  face,  having  put  a  prop  between 
the  teeth,  and  allow  air  to  be  breathed  until  respiration  is 
regular,  then  with  the  consent  of  the  patient  change  the  valve 
and  admit  the  gas.  The  substitution  will  hardly  be  noticed, 
and  in  from  one  to  two  minutes,  rarely  three,  anaesthesia  will 
be  produced,  lasting  long  enough  to  extract  from  one  to 
twenty  teeth,  according  to  the  susceptibility  of  the  patient,  the 
dexterity  of  the  operator,  and  the  difficulties  of  the  operation. 
The  narcosis  will  last  as  long  as  that  of  any  other  agent  which 
will  produce  it  as  quickly. 

Inhalation  of  gas  may  be  repeated,  anaesthesia  having  been 
induced  as  many  as  four  times  at  one  sitting. 

The  gas  may  be  allowed  to  escape  from  the  cylinder  into  a 


AN.KSTHESIA,  145 

ba^  from  wliicli  it  is  breathed,  or  better,  into  a  gasometer 
holdiiii^r  from  twenty  to  thirty  <^allons,  and  breathed  through 
a  tube  from  this.  This  insures  an  abundant  supply  and  pre- 
vents waste  of  gas. 

Any  inhaler  which  compels  the  reinhalation  of  expired  gas 
should  be  condemned. 

The  mode  of  death  from  inhalation  of  gas  is  from  failure  of 
respiration,  the  irritability  of  the  heart  persisting  for  some 
time  after  respiration  has  ceased. 

Ether. — Ether  is  a  safe  and  effective  anaesthetic,  and  is 
cspeciall)-  suited  to  prolonged  operations  on  account  of  its 
cheapness,  manageableness,  and  its  power  to  relax  the  mus- 
cular system.     It  also  stimulates  the  heart. 

Its  odor  is  very  disagreeable,  penetrating  and  persistent. 
It  passes  out  of  the  system  slowly.  In  full  strength  it  is  at 
first  irritating  to  the  air  passages  and  produces  coughing. 

The  ordinary  way  of  giving  ether  is  by  holding  a  towel 
folded  several  thicknesses  over  the  face  and  pouring  ether 
upon  it,  or  a  large  cone  sponge  over  the  face  without  covering. 
These  means  are  effectual,  but  wasteful  of  ether,  allowing  much 
to  escape  and  fill  the  apartments  with  the  vapor. 

A  more  economical  and  perhaps  neater  way  is  to  use  a  wire 
framework  lined  with  lint,  or  a  cone  sponge,  and  over  it  a 
towel  pinned  closely;  over  this  may  be  folded  a  paper  cover- 
ing, as  there  will  be  no  trouble  about  letting  the  patient  have 
air  enough.  Have  the  size  and  form  to  fit  the  face  without 
the  sponge  or  lint  coming  in  contact  with  it.  Have  the 
sponge  or  lint  wet  with  water,  as  ether  does  not  evaporate 
well  from  a  dry  surface. 

When  everything  is  in  readiness,  pour  on  to  the  inhaler  at 
first  sufficient  ether  to  produce  the  anaesthesia  (one  or  two 
ozs.),  as  removing  it  to  add  more  prolongs  the  operation  very 
much.  Let  the  patient  inhale  a  very  dilute  vapor  at  first  until 
the  membrane  of  the  air  cells  and  tubes  becomes  somewhat 
affected  and  a  state  of  tolerance  induced;  gradually  approach 
the    inhaler,  withdrawing  a  little    if  the   patient    chokes    or 


146  OPERATIVE    DENTISTRY. 

coughs,  until  the  full  strength  can  be  borne,  which  will 
usually  be  after  about  half  a  dozen  inhalations ;  then  crowd 
the  inhaler  close,  so  as  to  shut  out  nearly  all  air,  and  narcosis 
will  be  very  quickly  induced — in  from  two  to  four  minutes. 
If  the  patient  suffers  for  want  of  air,  more  must  be  admitted ; 
but  admit  no  more  than  is  necessary,  for,  by  exclusion  of  air, 
narcosis  is  much  more  quickly  produced.  Remove  the  inhaler 
and  perform  the  operation.  If  the  patient  is  anaesthetized  in 
this  way  and  then  allowed  to  come  to  at  once,  nausea  will 
seldom  be  experienced.  Ether  narcosis  should  not  be  repeated 
at  the  same  sitting,  as  it  is  almost  sure  to  produce  sickness. 

Conditions  Unfavorable  to  Anaesthesia. — Alcoholism  is 
a  condition  unfavorable  to  the  production  of  anaesthesia.  It  is 
generally  difficult  and  often  impossible  to  produce  it,  and  it  is 
attended  with  unpleasant  symptoms.  There  is  no  danger  in 
attempting  it,  but  if  unfavorable  symptoms  appear  the  attempt 
should  be  abandoned. 

Advanced  heart  disease  is  an  unfavorable  condition,  as 
enlarged  heart  with  atrophied  walls,  valvular  disease  or  fatty 
degeneration ;  but  in  these  cases  the  narcosis  is  no  more 
dangerous  than  the  shock  of  the  operation.  If  a  patient  is  able 
to  come  to  an  office  without  distress  or  inconvenience  on 
account  of  heart  trouble,  the  operator  may  feel  well  assured 
that  any  disease  of  the  heart  is  not  far  enough  advanced  to 
render  the  narcosis  at  all  perilous  on  that  account.  Diseased 
lungs  or  general  debility,  if  not  too  pronounced,  do  not  forbid. 

If  physical  depression  follows  the  use  of  an  anaesthetic,  it  is 
much  more  likely  to  be  the  effect  of  shock  than  of  the  narcosis. 

In  ether  narcosis  death  follows  from  failure  of  respiration. 

Chloroform. — Chloroform  has  a  direct  depressing  influence 
on  the  heart's  action.  It  is  also  a  very  powerful  agent,  and 
consequently  is  very  dangerous  to  use.  So  many  fatal  results 
have  followed  its  use  in  dental  practice,  that  to  continue  it 
seems  to  be  wholly  inexcusable. 

If  this  agent  be  given,  the  atmosphere  to  be  breathed  should 
not   contain   more  than   two  to   four  per  cent,  of  chloroform 


AN.KSTIlIiSIA.  147 

vai)or  ;  six  per  cent,  is  not  safe,  ei^ht  per  cent,  is  decidedly 
dangerous,  and  twelve  per  cent,  is  likely  to  prove  fatal.  Its 
odor  is  agreeable,  hence  it  is  pleasant  to  take,  and  the  tempta- 
tion to  use  it  is  great.  Death  occurs  from  failure  of  the  heart, 
and  it  is  likely  to  occur  in  the  early  stages,  often  before  con- 
sciousness is  lost.  A  single  inspiration  of  strong  vapor  may 
produce  the  fatal  result.  An  inhaler  should  be  used  which 
absolutely  controls  the  strength  of  the  atmosphere.  The  ready 
method  of  napkin  or  handkerchief  should  never  be  adopted. 

Chloroform  narcosis  is  usually  easy,  pleasant  and  prolonged, 
and  its  after-effects  not  disagreeable. 

Rapid  Breathing  as  a  Pain  Obtunder. — Place  the  patient 
in  a  reclining  position  upon  the  side.  Place  a  handkerchief 
o\'er  the  face  to  produce  quiet ;  have  the  patient  breathe  rapidly 
— about  one  hundred  times  a  minute,  rapidly  expiring.  In 
two  to  five  minutes  partial  or  entire  insensibility  is  obtained. 
This  is  more  applicable  to  women  than  men,  and  is  not  appli- 
cable to  children. 

Local  Anaesthesia. — Of  the  various  means  to  produce  local 
anaesthesia,  the  spray  of  ether  or  rhigolene  applied  by  the 
atomizer  is  the  most  convenient  and  effective.  The  teeth  and 
contiguous  parts  must  be  made  dry  and  kept  so,  and  the  spray 
directed  upon  them  gradually,  that  the  patient  may  bear  it 
without  shock  from  the  sudden  cold.  In  from  thirty  to  sixty 
seconds  the  full  effect  will  be  obtained,  when  the  teeth  may  be 
extracted.*' 

Too  great  or  long  continued  cold  must  be  avoided,  as  slough- 
ing may  result.  This  method  is  now  little  used,  the  cold 
being  so  painful. 

Ether  or  chloroform  applied  on  cotton  to  the  gum  around 
the  tooth  for  one  or  two  minutes  will  lessen  the  sensibility  in 
a  marked  degree. 

Unfavorable  Symptoms. — When  giving  gas,  the  face  of 
the  patient  sometimes  becomes  quite  livid.  This  is  due  in 
part  to  asphyxia  and  in  part  to  nervous  conditions,  bringing 
the  venous  blood  to  the  surface,  but  more  largely  to  impurities 


148  OPERATIVE    DENTISTRY. 

in  the  gas.  The  symptom  has  become  much  less  frequent 
since  the  introduction  of  hquid  gas.  This  is  not  to  be  con- 
sidered an  alarming  symptom,  and  absolute  purity  of  the  gas 
will  prevent  it. 

Nausea  occasionally  follows,  but  is  only  the  result  of  pro- 
found anaesthesia,  and  soon  passes  away,  requiring  no  treatment. 

In  a  few  instances  suspension  of  respiration  has  occurred, 
for  which  a  sudden  shaking  or  a  slap  upon  the  back  has  proved 
a  sufficient  remedy.  The  mode  of  death  from  gas  is  by  failure 
of  the  respiration,  and  if  suspension  of  the  respiration  continues, 
the  patient  should  be  laid  upon  the  floor  and  artificial  respira- 
tion be  resorted  to  as  long  as  irritability  of  the  heart  exists, 
which  may  be  for  an  hour  or  more. 

The  unfavorable  symptoms  of  ether  narcosis  are,  occasionally 
an  extreme  paleness.  The  remedy  for  this  is  the  temporary 
suspension  of  the  inhalation,  and  the  administration  of  some 
alcoholic  stimulant.  Muscular  contractions  with  irregular 
positions  and  motions  of  the  eyes,  indicating  an  undue  disturb- 
ance of  the  nervous  system,  is  an  annoying,  if  not  a  danger- 
ous symptom,  and  demands  prudence  and  moderation  in  the 
administration  of  the  anaesthetic,  if  not  an  entire  suspension. 

Nausea  and  vomiting  are  sometimes  persistent  and  distress- 
ing. Bromide  of  potassium  in  doses  of  fifteen  to  thirty  grains, 
repeated  if  necessary,  is  a  good  remedy. 

The  mode  of  death  from  ether  being  by  failure  of  respira- 
tion, if  danger  appears  from  this  cause,  resort  at  once  to 
artificial  respiration. 

The  unfavorable  symptoms  attending  the  administration  of 
chloroform  are  due  to  its  action  on  the  heart.  Its  less  serious 
effects  are  indicated  by  an  ashy  paleness  of  the  patient,  its  more 
serious  and  dangerous  effects  by  a  weakening  of  the  pulse,  or 
sudden  and  entire  failure  of  the  circulation.  The  remedy  for 
the  first  symptom  is  a  suspension  of  the  inhalation  and  a  free 
supply  of  air.  For  the  second,  promptly  lower  the  head  and 
shoulders,  elevate  the  limbs  and  employ  artificial  respiration. 
The  prospects  for  resuscitation  in  such  cases  are  not  favorable. 


CROWN    WORK. 


149 


CROWN    WORK 


The  mctliods  of  attachini^  porcelain  crowns  to  natural  roots 
are  very  numerous  and  varied. 

The  following  directions  will  serve  for  mounting  a  number 
of  kinds  of  serviceable  crowns.  For  an  exhaustive  discussion 
of  the  subject,  the  student  is  referred  to  the  files  of  the  Cosmos 
and  other  dental  journals  and  to  the  "  American  System  of 
Dentistry,"  Vol.  II. 

It  is  presumed  that  the  operator  understands  metallurgy, 
including  the  working  of  metals,  and  that  he  has  a  reasonable 
conception  of  the  principles  of  mechanics  and  the  ability  to 
apply  them.  A  student  is  not  expected  to  comprehend  all  the 
details  of  Crown  and  Bridge  work  without  an  instructor,  for 
it  is  not  possible  to  illustrate  and  describe  every  point  so  as  to 
be  fully  understood  by  a  novice. 

The  following  list  contains  the  most  of  the  instruments 
needed  for  this  work  : — 

Fig.  117. 


A  clasp  bender.  Fig.  117. 

Contouring  pliers.  Fig.  118. 

Long  pliers  for  soldering.  Fig.  119. 

Small  pliers  for  handling  solder,  Fig.  120. 


Fig.    iiS 


Fig.  119. 


Fig.  120. 


150 


CROWN    WORK. 


I^I 


Jack's  hard  bits,  Nos.  13  and  14.     (Fig.  12,  p.  32.) 
Bennett's  cliiscl  excavators,  Nos.  5  and  6. 
A  hoe-shaped  cutter. 
Excising  forceps,  Fig.  121. 


Fig.  jzi. 


Scissors.     Fig.  122  is  a  pair  of  surgical  scissors  for  cutting 


plate. 


Fig.  122. 


152 


OPERATIVE    DENTISTRY. 


Hand  and  engine  drills,  Nos.  14  and  15,  standard  wire  gauge, 
for  pulp  canals. 

Corundum  disks,  stones  and  points  for  engine. 

Soldering  clamps. 

Engine  burs — round  and  barrel,  Nos.  10  and  12,  and  wheel, 
Nos.  18  and  20. 

Bunsen  burners,  one  with  stand  for  drying  and  heating  cases 
and  for  soldering. 

One  mouth  blow-pipe. 

A  Knapp  nitrous  oxide  compound  blow-pipe  is  an  excellent 
addition. 

Copper  plate,  No.  32. 

Pattern  tin. 

Excavators — hatchets  and  hoes. 

Pliers,  Fig.  123. 

Fig.  123. 


Cutters,  Fig.  124,  for  trimming  plate. 

Investment  material,  equal  parts  plaster  and  marble  dust  or 
sand  or  asbestos. 

Die  metal,  melts  at  176°  F. 

Bismuth,  20  parts. 
Lead,         12     " 
Tin,  7     " 

Mercury,     4     " 


CROWN    WORK. 


153 


Or  die  metal,  melts  at  151°  F. 


Bismuth,    7j4  parts. 
Lead,  4         " 

Tin,  i^     " 

Cadmium,  2         " 


Or  die  metal,  melts  at  212°  F 


Bismuth,  2  jiarts. 
Lead,         i     " 
Tin.  I     " 


Fig. 124. 


Oxyphosphate  cement,  slow-setting. 

Gutta-percha,  soft-working. 

Finishing  and  polishing  instruments  and  materials. 

Straight-grained  wood  ;  birch  is  best. 

Cement  wax — beeswax  and  resin,  equal  parts. 

Iron  binding  wire.  No.  27. 

Pure  gold  plate,  No.  31. 

Twenty-two-carat  gold  plate, 
coin,   No.  31. 


Gold,     22,    1        <y  ,    , 

'       'I  No.  30,  or  gold 
Sliver,  2,  ) 


154  OPERATIVE    DENTISTRY. 

Gold,     1 8  parts.     ^ 
No.  I,  1 8-carat  solder,  <    Silver,     4     "  V  No.  27. 


Copper,  2 


i 


r  Five  dol.  gold  coin,  129  grs.^  ^^ 
No.  2,  1 8-carat  solder, -(  Spelter  solder,  12    "      ^ 

(  Silver  coin,  12    " 


27. 


Platinum  iridium  wire,  Nos.  14  and  15,  barbed,  or  a  screw 
thread  cut  upon  it. 

Platinum  plate,  No.  32,  may  be  substituted  for  the  pure  gold 
in  some  places. 

Preparing  the  Roots. — The  preparation  of  the  root  is 
nearly  the  same  for  each  method. 

Make  the  root  healthy  and  plug  the  apical  foramen.  (See 
page  100.) 

Cut  off  with  round  or  barrel  burs  and  corundum  disks,  the 
remaining  portions  of  the  crown  even  with  the  margin  of  the 
gum,  or  a  little  below  it,  so  the  joint  will  be  covered,  especially 
on  the  labial  surfaces  of  the  upper  front  teeth.  If  a  large  por- 
tion of  a  crown  is  to  be  removed,  cut  a  groove,  with  small  burs 
or  disk,  around  the  neck  of  the  tooth,  well  into  the  dentine, 
and  then  cut  it  off  with  the  excising  forceps,  P'ig.  124,  and  bur 
off  the  root  as  above  described. 

If  a  band  is  to  be  fitted,  dress  down  the  sides  of  the  root 
parallel  so  that  a  band  passing  over  the  end  will  fit  accurately 
throughout  its  whole  extent.  The  hoe-shaped  cutter  serves 
the  purpose  well.  Pass  the  instrument  under  the  gum  and 
draw  it  toward  the  surface,  scraping  off  the  projecting  portions 
until  the  portion  of  the  root  to  be  embraced  by  the  band  is 
reduced  to  a  uniform  size. 

Drill  out  the  root  canal  three-fourths  the  length  of  the  root, 
with  a  drill  corresponding  in  size  to  the  post-wire  to  be  used. 
The  opening  of  the  canal  may  sometimes  be  widened  to  admit 
a  post  flattened  at  the  cervical  portion,  as  in  a  Logan  or 
Parmly  Brown  crown. 

When  enlarging  and  forming  the  pulp  canal,  care  must  be 


CROWN    WORK. 


155 


exercised  to  follow  the  direction  of  the  canal  and  not  perfo- 
rate the  wall  of  the  root,  l^'or  a  t^uide,  use  a  flexible  probe  to 
determine  the  direction  and  depth. 

The  canal  must  not  be  drilled  beyond  any  considerable 
curve  of  the  root.  The  enj^ine  should  seldom  be  used.  Hand 
instruments  are  much  safer  and  more  accurate. 

Richmond  Crown. — The  crown  now  known  as  the  Rich- 
mond or  cap  crown  consists  of  a  metal  dowel  pin,  a  gold  cap 
and  a  porcelain  front,  the  latter  being  attached  by  a  gold 
backing  soldered  to  the  cap  and  pin.     (Fig.  125.)  ^» 

To  mount  one  of  these  crowns,  after  cutting  the  tooth  off 


Fig.  125. 


Fig.  126. 


and  before  grinding  it  to  exact  length,  dress  it  down  to  a  uni- 
form size.     (Fig.  126.) 

Pass  a  piece  of  fine  iron  or  silver  binding  wire  around  the 
root,  tighten  it  by  twisting  the  ends  together,  and  form  it  to 
the  root,  as  in  Fig.  143.  Remove  the  wire  without  changing 
its  form,  lay  it  upon  an  anvil,  and  place  upon  this  the  end  of  a 
piece  of  fine,  straight-grained  wood,  and  with  a  hammer  strike 
the  wood,  thus  embedding  the  wire  in  it.  Remove  the  wire, 
and  an  impression  the  exact  form  and  size  of  the  root  will  be 
left  in  the  wood.  Cut  down  the  wood  to  this,  just  removing 
the  impression  made  by  the  wire.  This  will  be  the  size  and 
form  of  the  root.  With  the  clasp-bender  fit  around  this  a  band 
of  twenty-two-carat  gold.  No.  31,  sufficiently  wide,  usually, 
about  one-fourth  of  an  inch,  to  allow  trimming  to  fit  the  festoon 


156  OPERATIVE    DENTISTRY. 

of  the  gum.  The  ends  of  the  band  may  lap,  the  inner  end 
being  filed  down  to  a  thin  edge.  Confine  this  with  binding 
wire,  and  try  it  upon  the  root  to  insure  its  exact  adjustment. 
Remove  and  unite  with  No.  i  solder,  then  replace  upon  the 
root  and  mark  the  line  of  the  festoon  of  the  gum;  remove  and 
file  or  grind  down  to  the  line.  When  properly  fitted,  the  band 
should  pass  under  the  gum  throughout  its  circumference,  but 
not  far  enough  to  impinge  upon  the  pericementum. 

Dr.  Baker  fits  a  band  "  by  using  copper  rolled  down  quite 
thin  and  three-fourths  of  an  inch  wide,  wrapped  about  the  root 
of  the  tooth  and  forced  up  under  the  gum.  A  ligature  is 
passed  around  both  ;  the  copper  band  is  burnished  down  and 
the  ligature  drawn  tight.  The  copper  band  will  now  fit  just 
about  as  we  want  the  gold  band  to  do.  Plaster  is  then 
inserted  in  this,  and  forced  up  against  the  end  of  the  root 
and  permitted  to  set.  Take  it  off  and  lengthen  the  root  end 
by  a  piece  of  paper  wrapped  about  it.  Then  the  melted  die 
metal  may  be  poured  into  it,  and  thus  a  perfect  model  of  the 
end  of  the  root  be  secured.  The  model  will,  perhaps,  need  a 
little  dressing  down  with  a  file,  when  the  gold  band  may  be 
fitted  around  it,  and  thus  avoid  annoying  and  painful  trying-on 
in  the  mouth," 

Some  operators  prefer  to  fit  the  band  directly  upon  the  root. 
This  may  be  readily  done,  but  it  is  more  painful  to  the  patient. 
To  do  this,  fit  the  band  as  nearly  as  possible  with  the  clasp- 
benders,  then  bind  it  with  wire  and  place  it  upon  the  root,  and 
complete  the  fit  with  a  burnisher  and  by  tightening  the  wire, 
remove  and  solder.  Remove  the  band  and  grind  off  the  root 
to  the  exact  length  required,  grinding  the  labial  side  a  little 
under  the  gum.  (Fig.  125,  a.)  Replace  the  band  and  mark  on 
the  inside  the  outline  of  the  surface  of  the  root.  Cut  away 
the  band  to  this  line,  when  it  will  be  found  to  correspond  to 
the  end  of  the  root.  Take  a  piece  of  pure  gold,  well  annealed, 
No.  31,  large  enough  to  cover  the  end  of  the  root.  Fit  and 
solder  this  to  the  band,  holding  it  in  place  with  pliers  or  with 
a  clamp,  making  a  cap  to  cover  the  end  of  the  root.    (Fig.  1 25  b.) 


CROWN    WORK.  157 

Place  the  cap'on  the  root,  and  with  a  sharp  drill  cut  a  hole  in 
the  cap  over  the  root  canal  large  enough  to  admit  the  dowel- 
pin  of  i)latinuni-iridiuni,  either  round  or  flattened.  The  dowel- 
pin  should  be  barbed  or  roughened.  Cut  it  off  somewhat 
longer  than  will  finally  be  needed.  Remove  the  cap  and  pin 
and  fasten  with  strong  cement  wax  ;  replace  to  secure  correct 
relation  of  pin  and  cap  ;  remove  carefully  and  invest,  and  when 
fully  set  wash  off  the  wax,  cut  off  the  superfluous  length  of 
pin,  and  solder.  Grind  off"  any  surplus  solder  or  pin  and 
place  the  capon  the  root.  Select  a  plate  tooth  with  cross  pins 
of  proper  shade,  size  and  form,  and  grind  it  to  fit  in  position. 
(F'ig.  125  c.)  Back  the  tooth  with  pure  gold,  No.  31,  fastening 
the  backing  in  position  by  bending  the  pins  a  little.  Usually 
the  backing  should  extend  to  the  cutting  edge,  but  occasion- 
ally, on  account  of  darkening  the  color,  it  may  be  cut  back 
nearly  to  the  pins. 

Attach  the  tooth  to  the  cap  with  wax,  place  in  the  mouth 
and  obtain  the  correct  position  of  the  crown.  Remove,  invest, 
solder  and  finish,  and  the  crown  is  ready  for  insertion.  (Fig. 
125,  D.) 

Make  the  crown  and  root  perfectly  dry,  mix  good,  slow- 
setting  oxyphosphate  of  zinc  cement,  rather  thin,  the  consist- 
ency of  common  cream  ;  place  some  in  the  root  canal.  A 
coarse  broach  serves  well  to  work  it  into  the  canal.  Fill  the 
cap  and  immediately  carry  the  crown  firmly  to  place  ;  hold 
until  the  cement  is  set,  when  the  surplus,  which  has  been 
pressed  out  around  the  root,  may  be  removed. 

The  six  anterior  teeth  are  made  as  above  described. 

To  form  a  bicuspid,  proceed  as  for  an  incisor  or  cuspid  until 
the  porcelain  front  is  fitted  and  backed,  then  fasten  the  crown 
to  the  cap  with  strong,  hard  wax,  adding  enough  of  the  wax 
to  equal  the  size  of  the  crown,  and  to  receive  the  impression 
of  the  occluding  teeth.  After  the  occlusion  has  been  obtained, 
remove  from  the  mouth  and  harden  the  wax  by  cooling,  then 
scrape  a  little  from  the  grinding  surface  to  shorten  the  bite  as 
much  as  will  equal  the  thickness  of  the  gold  plate.      A  piece 


158  OPERATIVE    DENTISTRY. 

of  pure  gold  well  annealed,  No.  31,  of  proper  size,  may 
be  conformed  to  the  grinding  surface  of  this  wax  model  by 
rubbing  down  with  a  ball  burnisher,  taking  care  that  the  outer 
edge  is  in  close  contact  with  the  gold  backing  of  the  porcelain 
front.  Invest  for  soldering,  wash  out  the  wax  and  fill  this 
space  with  pieces  of  gold  plate  set  edgewise,  of  proper  size,  to 
complete  the  contour,  then  flow  No.  2  solder  to  make  the 
crown  solid. 

Finish  and  insert  as  in  other  cases. 

Gold  Cap  Crowns. — For  molars,  the  gold  cap  crown  is 
generally  used,  the  porcelain  front  being  unnecessary  in  the 
back  part  of  the  mouth. 

Dress  down  the  remaining  portions  of  the  crown  with 
corundum  disks,  or  by  other  means,  to  a  uniform  size  corre- 
sponding to  the  neck,  preserving  such  parts  of  the  crown  as 
are  strong,  and  reducing  the  grinding  surface  sufficiently  to 
allow  for  the  thickness  of  the  cap. 

Fit  and  solder  a  band  as  for  a  front  tooth,  but  wide  enough 
for  the  length  of  the  crown,  and  trim  the  edge  to  fit  the  occlu- 
sion. Contour  the  band  by  bending  it  in  with  contouring 
pliers,  cutting  it  up  from  the  edge  a  little  if  necessary;  then  fill 
the  band  with  wax  and  get  the  full  impression  of  the  grinding 
surfaces  of  the  occluding  teeth.  Cool  the  wax,  trim  the  edges 
to  the  band,  and  form  to  its  surface  a  piece  of  pure  gold  plate 
in  the  same  manner  as  for  the  grinding  surface  of  a  bicuspid. 
Mark  its  position  on  the  band,  remove  the  wax,  replace  the 
cap  and  hold  it  in  position  at  some  point,  and  attach  with  No. 
I  solder.  Perfect  the  position  of  the  cap  and  insure  contact 
with  the  band  at  all  points,  hold  the  pieces  in  position  with 
pliers  or  wrap  with  binding  wire,  and  solder.  Place  a  con- 
siderable quantity  of  No.  i  solder  inside  and  flow  it  over  the 
cap,  to  strengthen  the  grinding  surface.  Finish  and  set  with 
cement. 

Caps  for  the  grinding  surface  may  also  be  made  by  striking 
up  with  dies  made  from  typical  teeth. 

A  very  good  contour  may  be  obtained  by  making  the  band 


CRUWN    WOKK. 


'59 


a  little  funnel-shaped,  lar^^er  at  the  top,  and  then  bending  in 
the  edge  to  the  typical  form  of  the  tooth,  cutting  the  band  in 
places  if  need  be,  so  that  it  may  slip  by. 

Then  place  on  this  the  crown  plate,  solder  and  finish. 

"  Very  artistic  results  can  be  obtained  by  striking  up  the  two 


Fig.  127. 


Fic,  128. 


halves  of  the  ferrule  and  a  crown-plate  upon  dies  made  from 
natural  teeth,  corresponding  as  nearly  as  may  be  in  size  and 
shape  to  the  typical  form  of  the  tooth  to  be  capped.  Figs  1 27, 
128  and   129  represent  a  series  of  such  dies  made  from  the 


Fig.  129. 


Fig,  130. 


model  molar  tooth  seen  in  Fig.  130.  It  will  be  observed  that 
around  the  neck  of  the  molar  a  groove  has  been  cut  down  to 
a  line  perpendicular  to  the  long  axis  of  the  tooth,  as  previously 
directed  in  the  instructions  for  preparing  roots  for  ferrules. 


l6o  OPERATIVE    DENTISTRY. 

In  order  that  the  edge  of  the  groove  may  not  be  too  sharply 
defined,  the  walls  of  the  tooth  should  be  beveled  down  to  the 
groove  edge,  and  at  the  same  time  ground  away  over  their 
entire  surface,  removing  in  the  process  a  layer  of  enamel  equal 
in  thickness  to  No.  27  standard  gauge,  or  about  that  of  the 
gold  plate  to  be  used  in  making  the  crown.  This  will  make 
the  gold  crown  more  nearly  the  exact  size  of  the  model  tooth  ; 
otherwise  it  will  be  larger  by  the  thickness  of  its  own  walls, 
and  the  natural  contour  will  thus  be  too  much  exaggerated. 

"The  model  seen  in  Fig.  127  represents  the  contour  of  the 
buccal  wall ;  Fig.  128  that  of  the  palatine  wall,  the  cervical 
groove  made  in  the  model  tooth  being  reproduced  in  each. 
Fig.  129  represents  the  grinding  surface  with  sharply-defined 
cusps. 

It  will  be  observed  that  exact  contour  of  the  palatine  and 
buccal  surfaces  has  been  prolonged  laterally  only  to  the  most 
prominent  point  in  the  proximal  curvature,  the  model  beyond 
this  point  being  built  out  at  such  an  angle  as  will  prevent  an 
under  cut,  and  consequent  breakage  of  the  sand  in  moulding 
the  die. 

"  The  dies  can  be  made  of  either  zinc  or  brass  (preferably  the 
latter),  and  for  each  there  should  be  prepared  counter-dies  of 
lead.  By  the  aid  of  these  an  almost  perfect  representation  in 
gold  of  the  shape  of  a  natural  tooth,  and  at  the  same  time  a 
perfect  adaptation  to  the  root,  can  be  secured. 

As  teeth  of  the  same  class  vary  greatly  in  size  and  shape, 
the  making  of  a  series  of  such  dies  for  each  class  is,  of  course, 
necessary,  if  the  operator  desires  to  be  prepared  for  cases  as 
they  present  themselves.  The  series  need  not,  however,  be 
very  extensive :  six  sets  for  the  upper  molars,  as  many  for  the 
lower  and  a  corresponding  number  for  the  upper  and  lower 
bicuspids  respectively,  will  be  found  ample,  as  the  several 
pieces  of  the  skeleton  crown  are  easily  susceptible  of  almost 
any  modification  in  their  general  contour  necessary  to  adapt 
them  to  a  tooth  of  their  own  type. 

"The  dies  are  readily  secured  by  taking  in  plaster  an  impres- 


CROWN    WORK.  l6l 

sion  of  the  buccal  and  palatine  half  of  the  tooth  selected  as  a 
model,  this  tooth  bein^  ^^rooved  at  the  neck  and  diminished  in 
size,  as  before  directed.  The  impressions  being  secured,  are 
varnished  and  oiled,  and  ])laster  run  into  them  after  the  usual 
manner  of  making  casts,  it  being  desirable,  for  convenience  in 
subsequent  manipulations,  to  make  the  pedestals  of  the  casts 
about  three  inches  long  and  two  inches  broad  at  the  base,  and 
tapering  upward,  so  that  they  may  readily  be  withdrawn  from 
the  sand  in  the  moulding  process,  by  which,  after  the  ordinary 
methods,  they  are  reproduced  in  the  metallic  form  as  dies  for 
swaging. 

"Swaging  the  several  pieces  of  the  crown  is  a  very^  simple 
process.  In  order  to  determine  the  dimensions  of  the  strip  of 
gold  to  be  used  in  their  construction,  a  pattern  in  sheet  tin  is 
very  readily  secured  by  simply  pressing  it  upon  the  die  with 
the  fingers  or  with  burnishers.  The  patterns,  which  should 
be  made  of  ample  size,  are  reproduced  in  22-carat  gold,  in 
thickness  No.  27  standard  gauge.  By  the  aid  of  pliers,  mal- 
lets and  counter-dies,  the  palatal  and  buccal  halves  of  the 
crown  are  then  swaged  to  position  upon  the  die  and  closely 
adapted  to  its  surface,  care  being  taken  to  press  them  well 
into  the  cervical  grooves. 

"To  secure  ample  margin  for  the  overlap,  their  free  ends  are 
somewhat  prolonged  beyond  the  mesial  line  of  the  model  tooth, 
the  shape  of  the  dies  readily  permitting  this.  As  thus  swaged, 
the  ends  will  diverge  somewhat  widely  from  the  natural  con- 
tour, but  by  placing  them  upon  the  model  tooth  (Fig.  130,  p. 
159),  the  free  ends  can  readily  be  pressed  and  burnished  into 
close  contact  with  its  proximal  walls,  the  fit  at  all  other  points 
being  perfect  if  the  dies  have  been  properly  constructed.  As 
the  natural  tooth  is  liable  to  be  broken,  it  is  well  to  mount  it 
upon  a  conveniently-shaped  plaster  pedestal,  sinking  the  roots 
up  to  the  bifurcation  in  plaster,  and  reproduce  the  tooth  and 
pedestal  in  metal.  This  is  most  readily  accomplished  by  mak- 
ing with  a  mixture  of  equal  parts  of  whiting  and  plaster-of- 
Paris  a  sectional    mould  of  the  tooth,  drying  the  mould  until 


1 62 


OPERATIVE    DENTISTRY. 


Fig.  1^1. 


steam  ceases  to  come  off,  and  pouring  in  melted  tin,  Babbitt's 
metal,  or  other  of  the  fusible  alloys. 

In  fitting  the  skeleton  crown  to  a  natural 
root  in  the  mouth,  each  half  of  the  ferrule 
is  separately  adapted  to  that  side  of  the  tooth 
to  which  it  belongs,  as  shown  in  Fig.  131, 
where  the  palatine  half  is  seen  pressed  up 
under  the  gum.  Thus  placed,  the  adapta- 
1  tion  of  the  half  ring  is  much  more  readily 
accomplished  than  is  that  of  the  full  ring, 
owing  to  the  ease  with  which  the  sides  can  be  compressed,  and 
also  to  the  greater  readiness  with  which  a  full  view  of  the  inte- 
rior can  be  obtained. 

"  The  adjustment  of  the  palatine  half  being  completed,  the 
buccal  half  is  also  shaped  to  the  tooth,  in  the  same  manner,  and 
to  make  the  overlaps,  both  ends  of  each  half  are  allowed  to 
extend  for  about  the  twentieth  of  an  inch  beyond  the  mesial 
line  of  the  proximate  surfaces  of  the  tooth.  The  limits  of  this 
overlap  should  be  clearly  marked  upon  both  sections  while 
they  are  in  position  around  the  tooth.  The  opposed  surfaces 
of  the  two  overlaps  should  then  be  very  carefully  beveled  to 
each  other,  as  already  directed  for  the  single  overlap  in  the 
cuspid  caps.  As  the  sections  are  curved  upon  all  sides,  the 
beveling  cannot  be  so  readily  accomplished  by  a  file  as  by  a 
small  corundum  wheel,  which  will  follow  all  curvatures  and 
rapidly  and  smoothly  reduce  each  surface  to  the  required 
extent.  The  bevels  being  made,  the  palatine  and  buccal  sec- 
tions of  the  crown  are  placed  in  position  around  the  root,  and 
the  overlapping  surfaces  adjusted  the  one  to  the  other,  the 
ends  of  the  buccal  section  being  spread  apart  sufficiently  to 
enable  them  to  override  the  ends  of  the  palatine  section,  after 
which  the  two  halves  are  pressed  firmly  together  around  the 
root,  while  guide-lines  are  made  along  and  across  the  mesial 
overlap.  By  aid  of  these  guide-lines  the  overlaps  are  re- 
adjusted after  the  sections  have  been  removed  from  position  in 
the  mouth.     To  hold  them  together,  a  small  clamp  of  iron  wire 


CROWN    WORK. 


i^^3 


may  be  used,  but  its  apiilication  is  often  difficult,  and  some- 
times the  clamp  becomes  united  to  the  \;o\l\  durin^^  the  solderin^^ 
process.  A  much  more  satisfactory  method  of  holding  the 
overlapping  surfaces  together  is  to  grasp  them  w  ith  a  pair  of 
suitabl)- shaped  spring-pliers,  and  then  partially  embed  the  two 
sections  in  a  small  mass  of  marble-dust  slightly  dampened  with 
water  and  contained  in  a  small  iron  cup  or  tray. 

"  After  the  marble-dust  is  well  packed  around  the  two  sec- 
tions, the  pliers  are  withdrawn  and  sufficient  borax  and  water 
applied  by  means  of  a  delicate  touch  from  a  camel's-hair 
pencil.  With  a  small  piece  of  i8-carat  gold  plate  the  joint 
can  then  be  readily  soldered.     Care  must,  of  course,  be  exer- 


Fir,.  132. 


cised  in  this  manipulation,  as  any  rude  jar  would  disturb  the 
adjustment  of  the  parts.  Fig.  132  shows  the  ferrule  embedded 
in  marble-dust  contained  in  the  small  iron  tray.  The  guide- 
lines will  be  observed  lengthwise  and  crosswise  of  the  overlap. 
The  two  sections  now  united  into  ohe  piece  are  replaced  upon 
the  tooth,  and  the  final  adjustment  is  perfected,  guide-Hnes 
being  marked  along  the  edge  of  the  distal  overlap,  as  shown 
for  the  mesial  surface  in  Fig.  132.  In  order  to  secure  a  per- 
fectly tight  fit,  press  the  edge  of  the  overlapping  plate  a  little 
beyond  the  guide-line,  grasp  with  the  pliers,  anneal,  to  counter- 
act the  tendency  to  spring,  as  explained  in  connection  with 
cuspid  caps,  and  solder  as  before. 

"  Making  the  crown-plate  and  attaching  it  to  the  ferrule  are 


164  OPERATIVE    DENTISTRY. 

comparatively  simple  processes.  Upon  the  die  (Fig.  129,  p. 
159),  made  from  the  masticating  surface  of  the  model  molar, 
(Fig.  130,  p.  159),  strike  up  a  shell  of  gold;  either  pure  gold 
(24-carat)  or  22-carat  gold  will  answer.  The  gold  must  not 
be  thicker  than  No.  27  standard  gauge  ;  and  if  pure  gold  is 
used,  it  may  be  made  very  much  thinner,  without  danger  of 
fusion  in  subsequent  processes.  With  a  thin  piece  of  pure 
gold  (32  standard  gauge),  an  almost  perfect  reproduction 
of  cusps,  sulci,  and  the  finest  markings  on  the  crown  can 
be  obtained,  the  artistic  effect  being  very  admirable.  The 
thicker  the  gold  employed,  the  less  sharply  defined  will  be  the 
outline  of  the  shell.  As,  however,  in  actual  use,  sharp  and 
prominent  cusps  have  generally  to  be  cut  down  to  secure 
proper  occlusion  wath  their  worn  antagonizers,  the  matter  is 
not  one  of  much  practical  importance.  The  shell  of  the  crown- 
plate  should  not  usually  extend  over  the  body  of  the  tooth 
much,  if  At  all,  beyond  the  base  of  the  cusps.  A  good 
general  rule  is  to  cut  the  edge  down  almost  to  a  level  with 
that  elevation  seen  on  the  under  surface  of  the  shell,  which 
represents  the  bottom  of  the  deepest  sulcus.  If  such  altera- 
tions have  been  made  in  the  outline  of  the  ferrule,  that  it  does 
not  correspond  to  the  outline  of  the  shell,  the  edges  of  the 
latter  can  easily  be  bent  in  or  out,  as  the  case  may  be,  until 
they  are  of  the  proper  shape.  The  edges  of  the  shell  should 
then  be  filed,  down  to  a  uniform  plane,  so  that  when  laid  upon 
a  smooth  and  level  surface  it  will  touch  at  all  points. 

The  necessity  for  the  nicety  of  jointing  is  evident,  since 
even  a  very  small  gap  between  the  edge  of  the  shell  and 
the  box-plate  would  afford  an  avenue  of  escape  for  the 
i8-carat  filling,  should  it  become  fused  in  this  or  subsequent 
heatings. 

For  this  reason  great  care  must  be  taken  in  fitting  together 
the  ferrule  and  crown-plate,  not  to  fill  or  cut  away  the  protec- 
tive shell  or  box.  When,  however,  the  ferrule  and  crown- 
plate  are  well  united  by  i8-carat  gold,  this  precaution  is  no 
longer  necessary,  as  in  all  subsequent  heatings  the  completed 


CROWN    WORK.  165 

crown  will  be  subjected  to  a  temperature  only  sufficient  to 
melt  the  ^okl  and  zinc  solder  employed. 

Fig.  133  shows  the  hollow  shell.  Fii^.  134  the  shell  filled 
with  18-carat  gold,  and  Fig.  135  the  filled  shell  and  bo.\-plate 
clamped  together  preparatory  to  soldering.  Fig.  136  is  the 
ferrule  prepared  for  the  crown-plate.  To  complete  the  crown, 
all  that  remains  is  to  perfect  the  occlusion,  at  the  same  time 
making  a  close  joint  between  the  crown-plate  and  ferrule,  and 
solder  them  together.  In  making  the  ferrule,  its  free  edge 
siiould  have  been  brought  almost,  but  not  quite,  up  to  the 
masticating  surface  of  the  antagonizing  teeth. 

"  In  establishing  occlusion,  all  that  is  necessary  is  to  cut 
away  from  this  free  edge  enough  gold  to  allow  the  crown- 
plate  to  slip  in  between  it  and  the  occluding  teeth. 

Fig.  133.  Fig.  134.  Fig.  135.  Fig.  136. 


By  filling  the  ferrule,  while  in  position,  with  wax,  taking  the 
"  bite  "  after  the  ordinary  manner,  and  making  a  small  articu- 
lating model,  this  detail  can  be  accomplished  out  of  the  mouth 
even  more  conveniently  than  in  it ;  by  either  method,  how- 
ever, the  process  is  not  difficult.  In  cutting  away  the  edges 
of  the  ferrule,  great  care  must  be  taken  that  it  is  done  uni- 
formly, so  that  it  will  fit  perfectly  the  under  surface  of  the 
crown-plate,  and  on  such  a  plane  as  w^ill  allow  the  grinding 
surface  of  the  crown  to  come  in  contact  with  the  occluding 
tooth  or  teeth  at  the  most  desirable  angle.  The  line  of  occlu- 
sion being  established,  the  crown-plate  and  ferrule  may  then 
be  joined.  A  clamp,  such  as  seen  in  Fig.  137,  will  hold 
them    together,    and   the    projecting    edge    of  the    box-plate 


1 66  OPERATIVE    DENTISTRY. 

serves  as  a  convenient  ledge  upon  which  the  small  pieces  of 
l8-carat  gold  plate  used  as  a  solder  can  rest.     Frequently, 
in    fitting  to  place  between  adjoining 
"^'  '''''  teeth,  this    ledge   upon  the  proximal 

surfaces  of  the  crown  will  necessarily 
have  been  removed,  but  the  buccal 
and  palatal  edges  need  not  be  dis- 
turbed until  the  final  finishing  of  the 
crown.  Borax  must,  of  course,  be 
carefully  introduced  into  the  joint  to  be  closed. 

The  crown  is  placed  upon  a  suitable  support — preferably  the 
bed  of  marble-dust,  which  much  lessens  its  liability  to  fall 
off — and  by  the  judicious  application  of  heat  the  joint  can  be 
safely  and  securely  closed.  The  crown  is  then  ready  for  the 
finishing  processes.  The  processes  consist  in  filing  off  the 
projecting  edge  of  the  box-plate  flush  with  the  face  of  the 
crown,  smoothing,  contouring  and  beveling  the  free  edge  of 
the  ferrule  as  directed  for  cuspid  caps,  and  polishing  with 
emery-powder,  Scotch-stone,  etc.,  the  final  polish  being  given 
by  rouge  carried  on  swiftly-revolving  felt  wheels.*  " 

THE    MANDREL  SYSTEM. 

"  In  all  of  the  various  systems  of  crown-  and  bridge-work 
which  have  been  brought  to  the  attention  of  the  dental  pro- 
fession, one  very  important  point  seems  to  have  been  over- 
looked, viz.  :  The  comparative  conformation  of  the  necks 
of  teeth  of  different  classes.  The  general  forms  of  the  crowns 
of  teeth  have  long  been  well  known,  but  so  far  as  we  are 
informed  no  systematic  classification  of  the  shapes  of  the 
necks  has  heretofore  been  made.  It  will  appear  that  such  a 
classification  ought  to  form  the  basis  of  any  system  of  crown- 
and  bridge-work  claiming  a  scientific  foundation. 

"  To  lay  the  groundwork  of  the  system  here  described,  a 

*Dr.  Litch,  "  Am.  Syst.  Dent.,"  ii,  840. 


THE  .mani)ki:l  .s\.stkm.  167 

lar^c  number  of  human  teeth  of  the  various  classes  were 
secured,  their  crowns  cut  off,  ;uul  the  shapes  of  the  stumps 
accurately  determined,  thereb)-  developing  the  fact  that,  no 
matter  how  great  differences  may  exist  in  the  ap[)arent  shapes 
of  the  crowns  of  iiulixidual  teeth  of  a  gi\en  class,  there  is 
a  remarkable  conformity  in  the  configuration  of  their  necks. 
That  is,  the  necks  of  the  upper  cuspids,  for  instance,  were 
found  to  have  a  fixed  type,  from  which  the  variations  were 
very  slight  as  to  shape,  though  there  appeared  to  be  no  exact 
standard  of  size.  So  of  the  other  classes,  with  the  single 
exception  of  the  superior  molars,  in  which  two  distinct  forms 
were  found,  the  first  being  those  in  which  the  buccal  roots 
were  wider  than  the  palatal  ;  the  second,  those  in  which  the 
reverse  condition  was  found,  the  single  palatal  root  being 
wider  at  its  junction  with  the  crown  than  the  two  buccal 
roots.  The  occurrence  of  roots  of  the  second  class  being 
rather  exceptional,  the  first  class  was  accepted  as  the  type. 

"The  configuration  of  the  necks  of  all  the  teeth  having  been 
determined,  a  set  of  mandrels  for  shapii}g  collars  to  fit  them 
was  devised.  The  set  (Fig.  138)  consists  of  seven  mandrels, 
six  of  which  are  double-end.  Their  shapes  are  modeled 
upon  the  general  typal  forms  of  the  necks  of  the  teeth  which 
they  represent,  and  they  are  made  tapering  to  provide  for 
all  required  variations  in  size.  The  illustrations  are  about 
two-thirds  actual  size,  the  longest  instruments  being  nine 
inches  in  length. 

"  The  cross-sections  show  the  shapes  and  proportionate  sizes 
at  the  greatest  and  least  diameters.  The  long  taper  permits 
the  most  minutely  accurate  adjustment  of  the  collars. 

"  No.  I  is  a  double-end  mandrel,  for  superior  molars,  right 
and  left ;  No.  2  is  a  single  mandrel,  for  superior  bicuspids, 
right  and  left ;  No.  3  is  double-end,  for  superior  cuspids,  right 
and  left;  No.  4,  double-end,  for  superior  centrals,  right  and 
left;  No.  5,  double-end,  for  inferior  molars,  right  and  left; 
No.  6,  double-end,  for  inferior  centrals,  laterals,  cuspids,  and 
first  bicuspids,  right  and  left ;    No.  7,  double-end.  one  end  for 


Fig.  138. 


No.  1. 


No.  2.  No.  3.  No.  4.  Ho.  5.  No.  0. 

Mandrels  for  Slinping  Seamless  Tooth-Root  Collars. 
168 


THE    MANORKL   SYSTKM.  I  69 

the  superior  lateral  incisors,  the  other  for  those  bicuspids  in 
which  a  bifurcation  of  the  roots,  or  a  tendency  in  that 
direction,  extends  across  the  neck  to  the  crown  in  the  form 
of  a  depression  on  one  or  both  proximal  surfaces.  The  fore- 
going scheme  com[)rehcnds  all  the  teeth  of  the  permanent 
set  except  the  secontl  inferior  bicuspids.  The  necks  of  the.se 
approximate  those  of  the  superior  central  incisors  so  closely 
in  shape  that  it  was  deemed  inexpedient  to  make  a  separate 
mandrel,  as  the  No.  4  mandrel  will  serve  for  both. 

"  The  collars  or  bands  are  made  seamless,  of  No.  30  (Amer- 
ican gauge)  gold  plate,  twenty-two  carats  fine.  Fifteen  sizes, 
each  of  three  widths  (one-tenth,  two-tenths,  and  three-tenths 
of  an  inch)  are  made  (Fig.  139),  which  it  is  believed  will  cover 
all  requirements.  These  collars,  although  devised  as  a  part 
of  the  system,  can  be  used  in  all  methods  of  crown-  and  bridge- 
work  which  require  bands,  and  possess  many  ad\'antages 
over  any  others.  They  are  really  labor-saving  devices,  as 
their  use  saves  the  time  and  trouble  of  making,  and  there  is 
no  danger  of  their  coming  unsoldered,  when  the  pins  or  the 
backing  of  the  crown  is  being  soldered;  and  there  are  no 
hard  spots  to  give  trouble  in  burnishing,  as,  for  instance,  close 
to  the  root,  after  the  collar  has  been  shaped  and  placed  in 
position,  the  whole  surface  being  uniformly  soft. 

"  The  seamless  collars  are  especially  adapted  to  removable  or 
detachable  bridge-work.  They  are  so  constructed  that  Nos. 
I,  16  and  31  exactly  fit  into  or  telescope  with  Nos.  2,  17  and 
32,  and  so  on  through  the  entire  set,  each  collar  fits  into  the 
series  next  higher,  so  that  a  root  may  be  banded  with  one  size, 
and  the  size  next  larger  used  to  form  the  tube  for  the  telescop- 
ing crown.  The  advantages  for  the  construction  of  cap  crowns 
are  obvious. 

"  The  other  appliances  specially  devised  for  this  system  are  a 
reducing-plate  or  contractor,  a  pair  of  collar-pliers,  and  a 
hammer. 

"The  contractor  (Fig.  140)  contains  holes  which  are  com- 
plementary in   shape   to  the  mandrels.     The  mandrels  being 


o 
o 

O 


OR 


>0 


M 


;o 


D 
D 


o 


J  M 
00 


M 


M    (]_ 


o 


170 


THK    MANDREL    SYSTEM, 


171 


applied  to  the  inner  circumference  of  the  collars,  while  the 
contractor  must  admit  the  collars  themselves,  the  short 
taper  of  the  holes  in  the  contractor  necessarily  covers  a  greater 
ransfe   of  size    than   is   shown   in   the    mandrels.      With   this 


Fig.  140. 


appliance  collars  can  be  evenly  and  accurately  reduced  in  size 
at  the  edges,  without  burring  or  bucking.  The  illustration 
is  actual  size. 

"The  collar-pliers  (Fig.  141)  arc  for  contouring  the  collars 


Fig.  141. 


to  shape,  one  beak  being  made  convex,  and  the  other  con- 
cave to  correspdnd.  With  this  appliance  the  slightest  changes 
required  in  the  contour  in  the  collar  are  easily  made.  About 
a  half  inch  from  the  extremity  of  the  concave  beak  a  small 


1/2 


OPERATIVE    DENTISTRY. 


bar  of  flat  steel  is  attached  to  it  by  means  of  a  screw.  The  free 
end  of  the  bar  has  a  minute  projection  upon  one  face,  the  other 
being  reinforced  to  fit  into  the  concavity  of  the  beak.  In  the 
centre  of  the  face  of  the  convex  beak  is  a  depression,  into  which 
the  projection  on  the  steel  bar  strikes,  making  a  very  efficient 
punch  for  forming  guards  or  stops  to  prevent  the  collars  from 
being  forced  too  far  under  the  gum.  The  depression  in  the 
convex  beak  being  slightly  larger  than  the  projection  or  punch, 
the  metal  is  not  cut  through,  but  merely  raised  on  the  side  oppo- 
site to  the  punch.  The  punch  attachment  being  pivoted,  can 
be  swung  to  one  side  when  not  in  use. 

"  Fig.  142  is  a  mallet  or  hammer  with  a  steel  face  and  horn 
peen.     The  handle  is  nine  inches  long. 

"One  of  the  appliances  required  is  a  lead  anvil,  which  being 

Fig.  142. 


only  apiece  of  soft  lead,  say  two  by  three  inches,  and  an  inch 
thick,  is  not  illustrated.  The  female  die  of  an  ordinary  case 
will  answer  very  well. 

"To  illustrate  the  uses  of  these  appliances,  take  a  case  in 
which  the  two  inferior  bicuspids  of  the  left  side  are  missing, 
and  the  crowns  of  the  cuspid  and  first  molar  so  badly  decayed 
that  the  probabilities  are  that  they  will  soon  fall  victims  to  the 
forceps.  The  old-time  way  would  have  been  to  extract  the 
molar  and  cuspids  and  make  a  partial  plate.  Examination, 
however,  shows  that  the  roots  of  these  two  teeth  are  in  good  con- 
dition, affording  an  excellent  opportunity  for  the  construction 
of  a  piece  of  bridge-work. 

"  With  a  corundum  point  or  rotary  file  cut  off  the  remain- 


THK    MANDKKL    SYSTKM. 


173 


iji<^  portions  of  the  crowns  level  with  the  ^um-margins. 
Prepare  the  roots  in  any  of  the  well-known  ways,  thorou^hl)- 
cleansing  the  apical  portions,  and  filling  them  with  what- 
ever material  is  desired,  being  careful  only  that  the  work- 
is  well  done.  h'or  the  better  retention  of  the  filling  ma- 
terial to  be  placed  in  the  pulp-chamber,  retaining  grooves 
can  be  made,  or  retaining-posts  inserted.  Take  a  piece  of 
binding  wire  (No.  26,  American  gauge),  say  two  and  a  half 
inches  long,  pass  it  around  the  neck  of  the  molar  stump,  cross 
the  free  ends,  and,  holding  the  wire  in  place  with  one  finger, 
twist  the  ends  with  a  pair  of  flat-nosed  pliers  until  the  wire 
clasps  the  neck  closely  at  every  point  (Fig.  143).  When 
there  are  any  irregularities  in  the  contour  of  the  tooth,  it  is 
necessary  to  press  the  wire  into  them  with  a  proximal  burn- 


FlG.  143. 


Fig.  144. 


isher.  It  is  obvious  that  the  ring  thus  formed  will  show  the 
exact  size  and  shape  of  the  neck  of  the  tooth.  Remove  the 
ring  carefully,  lay  it  on  the  lead  anvil,  put  over  it  a  piece  of 
flat  metal,  and  with  a  smart  blow  from  a  hammer  drive  the 
wire  into  the  lead  (Fig.  144).  Upon  removing  the  wire  an 
exact  impression  of  the  ring  will  be  left  in  the  lead  anvil. 
(This  part  of  the  work,  as  indeed  all  others,  should  be  done 
carefully  as  described.  The  wire  ring  may  be  driven  into  the 
lead  by  a  direct  blow  of  the  hammer  face,  but  the  blow  might 
not  strike  equally,  and  the  interposition  of  the  flat  metal  held 
level  ensures  an  even  impression.  A  piece  of  an  old  file  is  best, 
as  the  file  cuts  keep  the  wire  from  slipping.) 

"  Next  cut  the  wire  ring  at  the  lap,  straighten  out  the  wire, 


174 


OPERATIVE    DENTISTRY. 


and  select  a. suitable  collar  by  comparing  the  length  of  the  wire 
with  the  straight  lines  in  the  diagram  (Fig.  139,  p.  170),  which 
show  the  inside  diameters  of  the  various  sizes.  Should  none  of 
these  correspond  exactly,  take  preferably  the  next  size  smaller. 
It  will  be  remembered  that  the  collars  are  No.  30  in  thickness, 
while  the  wire  with  which  the  conformation  is  secured  is  No. 
26.  This  difference  permits  the  collar  when  contoured  to 
shape  to  enter  the  lead  impression  readily — a  decided  advan- 
tage in  fitting.  Having  selected  the  collar,  fit  it  to  mandrel 
No.  I  with  the  peen  of  the  hammer,  holding  it  upon  the  lead 
anvil  and   using  a  slight  pushing  force  to  help   in  stretching 


Fig.  145. 


Fig.  146. 


and  forming  it  (Fig  145).  Having  driven  the  collar  to  form, 
remove  it  from  the  mandrel  and  try  in  the  lead  impression. 
If  it  does  not  fit  exactly,  return  it  to  the  mandrel  and  stretch 
it  a  little,  when  it  will  usually  fit  perfectly,  as  the  mandrels 
have  been  designed  carefully  to  the  average  shapes  which 
obtain  in  the  great  majority  of  tooth-necks.  In  the  exceptional 
cases  where  the  collar  does  not  fit,  it  can  be  readily  contoured 
to  the  exact  shape  with  a  pair  of  flat-nosed  pliers.  Of  course, 
if  it   fits  the  impression  in  the  lead  it  will  fit  the  neck  of  the 


THE    MANDREL   SYSTEM. 


175 


tooth,  always   proxided  the  measurement   and  the  impression 
have  been  carefully  made. 

"  If  the  collar  or  band  has  been  accidentally  stretched  too 
much,  or  if,  for  any  reason,  when  brought  to  shape,  it  is  too 
large,  its  root-end  can  easily  be  reduced  to  the  proper  size  by 
the  use  of  the  contractor.  Place  the  edge  of  the  collar  which 
is  to  fit  the  root  in  the  proper  hole  ;  hold  it  level  with  a  piece 
of  file,  as  in  taking  the  lead  impression  of  the  ring,  and  tapping 
lightly  on  the  file,  drive  the  collar  into  the  plate  (Fig.  146), 
until  the  proper  reduction  is  made.  The  collar  is  next 
'  festooned  '  to  correspond  to  the  shape  of  the  maxillary  ridge. 


Fig.  147- 


Fig.  148. 


Lay  it,  gum  edge  up,  on  the  lead  anvil,  and  with  the  piece  of 
flat  file  and  the  hammer  drive  it  into  the  lead.  A  few  cuts 
with  a  half-round  file  across  the  proximal  diameter  will  con- 
form the  edges  to  the  surface  of  the  ridge  (Fig.  147).  Then 
place  the  collar  in  position,  and  having  ascertained  just  how 
far  it  should  go  down  on  the  root,  remove  it,  and  with  the 
small  spring  punch  on  the  collar-pliers  form  projections  on 
the  inside  of  the  band  at  the  proper  points  to  serve  as  stops, 
which  resting  on  the  top  of  the  root  will  prevent  the  collar  from 
being  forced  further  down  upon  it  than  is  desirable  *(Fig.  148)." 


*  Cosmos,  XXVIII,  478. 


1/6  OPERATIVE    DENTISTRY. 

This  collar  may  support  a  porcelain  crown  or  an  all-gold 
cap,  and  upon  these,  for  abutments,  a  bridge  may  be  adjusted 
if  needed. 

Crown  with    Metal    Post    without    Band. — The    crown 
Fig  149      shown  in  Fig.  149  is  simple,  easily  made,  and  when 
well  adjusted,  perfect  in  appearance. 

For  this  crown  the  root  should  be  cut  off  a  little 
below  the  margin  of  the  gum,  and  hollowed  to  corre- 
spond to  the  festoon.  This  may  be  done  with  an  oval 
file,  or  better,  with  engine  burs,  barrel  or  round. 

Drill  the  canal  as  before  described,  insert  the  wire 
for  the  post,  and  cut  it  off  so  that  it  projects  one-eighth 
of  an  inch.  Take  a  piece  of  platinum  plate  about  the 
size  of  the  end  of  the  root,  thickness  No.  33,  place  it 
over  the  end  of  the  root,  and  with  the  finger  obtain  the  imprint 
of  the  wire.  Punch  a  hole  in  the  plate  large  enough  to  admit 
the  wire,  place  it  over  the  pin  on  the  root,  and  with  burnishers 
bend  to  the  form  of  the  end  of  the  root.  Remove  plate  and 
pin  together  and  fasten  with  strong  wax,  replace  on  the  root 
to  insure  accurate  position,  remove  carefully,  invest  in  mixture 
of  equal  parts  plaster  and  sand  or  pumice  stone.  Warm  the 
piece  slightly  and  remove  the  wax,  or  use  boiling  water. 
When  dry,  solder  with  20-carat  solder,  using  only  enough  to 
unite  the  two  pieces,  then  insert  and  burnish  every  portion  to 
fit  the  root.  The  outline  of  the  root  will  be  marked  upon  the 
plate ;  remove  and  cut  away  to  the  exact  size  of  the  root. 
Reinsert,  and  be  sure  that  the  labial  edge  of  the  root  is  short 
enough  to  allow  the  margin  of  the  gum  to  completely  cover 
the  joint,  and  with  No.  2  modeling  composition  get  a  correct 
impression  of  this  and  the  adjoining  teeth.  Place  the  cap  in 
its  position  in  the  impression  and  make  a  plaster  model. 
Grind  a  tooth,  previously  selected,  of  proper  color  and  form 
to  fit  this  model.  Fasten  the  tooth  to  the  cap  with  strong  wax 
and  try  in  the  mouth  to  prove  the  position  and  occlusion,  then 
invest,  back  the  tooth  with  No.  28  22-carat  gold  plate,  and 
solder  and  finish.  Barb  the  pivot  wire  with  a  sharp  knife,  and 
the  piece  is  ready  for  insertion. 


iiiE  i,()(;an  ckown. 


177 


Protect  the  root  from  moisture,  dr)-  the  canal  thorouglily, 
and  in  it  place  a  moderate  amount  of  easy-working  gutta- 
percha. Hold  the  pin  in  the  flame  of  the  alcohol  lamp  until 
it  and  the  tooth  are  quite  hot,  then  carry  it  slowly  and  firmly 
to  place.  The  hot  pin  softens  the  gutta-percha  and  the  firm 
pressure  expresses  the  surplus.  When  cool,  cut  away  the  sur- 
plus with  a  sharp  instrument,  and  smooth  the  edges  with 
chloroform  or  oil  of  cajeput. 

Oxyphosphate  of  zinc  also  makes  a  good  setting  for  these 
crowns. 

The   Logan  tooth-crown  is  porcelain,  with  the  post  baked 


Fici.  150. 


P"k;.  isi. 


Fig.  152. 


Fig.  153- 


into  the  end  of  the  crown.  The  post  is  widened  at  the 
cervical  portion. 

Dr.  W.  Storer  How  gives  the  following  illustrated  descrip- 
tion oC  the  best  methods  of  mounting  them  ; — the  root  is 
presumed  to  be  suitably  prepared. 

Fig.  150  shows  a  superior  right  central  root,  an  end  appear- 
ance of  the  same,  and  a  Logan  crown,  front  view.  Fig.  151 
exhibits,  at  a  right  angle  to  the  plane  of  the  first  figure,  the 
same  root,  its  end;  and  the  Logan  crown,  side  view.  In  both 
figures  the  pulp-canal  is  supposed  to  have  been  first  drilled  to 
a  gauged  depth  with  an  engine  twist-drill,  No.  151,  and  then 


178 


OPERATIVE    DENTISTRY, 


enlarged  by  means  of  a  fissure-bur,  No.  70,  to  the  tapering 
form  shown ;  the  walls  being  subsequently  grooved  with  an 
oval  bur,  No.  90.  The  enlarged  section,  Fig.  152,  shows  the 
crown  adjusted  on  the  root  by  means  of  cement  or  gutta- 
percha, which  surrounds  the  post  and  fills  all  the  spaces  in 
the  root  and  crown.  Fig.  153  shows  the  completed  crown. 
Fig.  154  exhibits  a  bifurcated  bicuspid  root,  its  end  appear- 
ance, and  a  Logan  crown  adjusted  to    the   root.     Fig.    155 


Fig.  154. 


Fig.  155. 


Fig.  156. 


III  1 ! 

Fig.  157. 


Fig.  t  = 


Fig.  159. 


Fig.  i6j.  Fig.  i6i. 


illustrates  the  best  manner  of  bending  the  post.  Fig.  156 
shows  a  split  post,  and  its  adaptation  to  a  bifurcated  bicuspid 
root  is  seen  in  Fig.  157.  Figs.  158  and  159  exhibit  the  mode 
of  mounting  the  Logan  crown  on  a  superior  molar  root,  and 
Figs.  160  and  161  the  same  crown  in  its  relations  to  an  inferior 
molar  root. 

The  suitable  preparation  of  the  bifurcated  roots  of  some 
bicuspids  and  of  all  the  molars  is  a  matter  involving  difficulties 


THE    LOGAN    CROWN.  1 79 

of  an  unusual  cliaractcr  and  rcquirinj^  ^food  jud^nnent.  The 
feasibility  of  splittin^tj  the  post  of  a  Loj^an  crown  to  adapt  it 
to  the  bifurcated  root  of  a  bicuspid  is  shown  by  Figs.  156 
and  157.  Tliis  example  directs  attention  to  the  peculiar 
shape  of  the  new  post,  in  which  there  is  effected  such  a 
distribution  of  its  metal  tiiat  its  greatest  strength  is  in  the 
line  of  the  greatest  stress  that  will  in  use  be  brought  to  bear 
on  the  crown,  while  the  least  metal  is  found  at  the  point  of 
the  least  strain  ;  the  applied  part  of  the  post  being  in  outline 
nearly  correspondent  to  that  of  the  root  itself  The  pulp- 
canal  is  likewise  conformably  enlarged  to  receive  the  largest 
and  stiffest  post  which  the  size  and  shape  of  the  root  will 
permit. 

The  fitting  of  a  Logan  crown  to  a  root  is  best  done  by  the 
use  of  a  wet  stump  wheel  in  the  engine  hand-piece,  a  method 
which  affords  the  greatest  facility  for  the  slight  touches 
required  to  abrade  the  thin  cervical  borders  of  the  crown, 
which  may  by  this  means  be  done  without  encroachment  on 
the  post. 

The  recess  in  the  Logan  crown  provides  a  receptacle  for  a 
considerable  interior  body  of  cement  that  will  be  deep  enough 
to  be  self-sustaining  internally,  and  yet  allow  the  peripheral 
portions  of  the  root  and  crown  to  approach  each  other  so 
closely  that,  though  only  a  film  of  packing  remain,  it  will  still 
be  strong  enough  to  insure  the  persistent  tightness  of  the 
joint.  This  annular  boss  if  formed  of  amalgam  also  adds 
strength  in  some  cases  to  the  mount. 

When  enough  of  the  natural  crown  remains,  it  is  well  to 
leave  standing  some  of  the  palatal  portion,  and  cut  the  root 
under  the  gum  margin  at  only  the  labial  part,  as  shown  by 
Fig.  164.  Thus  the  labial  joining  of  the  root  and  crown  will 
be  concealed,  and  the  other  parts  of  the  joint  will  be  accessible 
for  finishing  and  keeping  clean.  The  Logan  crown  may  be 
ground  until  a  large  part  shall  have  been  removed  for  adapta- 
tion to  the  occluding  tooth  or  teeth  without  serioush'  impairing 
its  streniTth.     This    crown    also  in  such   cases  maintains  the 


l80  OPERATIVE    DENTISTRY. 

translucency  which  is  one  of  its  pecuhar  excellences,  owing  to 
its  solid  porcelain  body,  and  the  absence  of  a  metallic  backing 
or  an  interior  largely  filled  with  cement  or  amalgam. 

The  distal  buccal  root  of  the  natural  superior  molar  is  nearly 
always  too  small  to  receive  a  post  of  any  useful  diameter,  and 
therefore  the  Logan  superior  molar  crown  has  but  two  posts, 
which  like  those  of  the  inferior  molar  crown  are  square,  and 
thus  may  be  easily  barbed,  as  may  also  the  ribbed  posts  of  the 
crowns  for  the  anterior  tooth-roots.  These  posts  are  large 
enough  in  all  the  Logan  crowns  to  answer  in  any  given  case, 
and  can  of  course  be  easily  reduced  to  suit  thin  or  short  roots. 

Any  of  the  cements  or  amalgams  may  be  used  in  fixing 
these  crowns,  but  good  gutta-percha,  softened  at  a  low  heat 
and  quickly  wrapped  around  the  heated  crown-post,  which  is 
at  once  seated  in  the  root,  forms  the  best  mounting  medium, 
and  has  the  great  advantage  ^f  permitting  a  readjustment,  or 
if  need  be  the  ready  removal  of  the  crown  by  grasping  it  with 
a  pair  of  hot  pliers  or  forceps,  and  holding  it  until  the  gutta- 
percha is  sufficiently  softened. 

An  excellent  combination  for  some  cases  is  accomplished 
by  fitting  a  narrow  seamless  gold  collar  over  the  neck  of  a 
root  prepared  like  that  of  Fig.  155,  and  then  adjusting  and 
mounting  a  Logan  crown  in  the  manner  described  above,  with 
the  result  shown  by  Fig.  164. 

This  collar  combination  is  available  in  very  difficult  cases, 

as  for  instance  when  a  root  is  de- 

F,c.  Z62.      Fig.  163.     f:g.  164.     ^^yg^  f^j-  bcncath  the  gum,  as  seen 

in  Fig.  162.  Such  an  operation 
when  completed  would  appear  in 
vertical  section  like  Fig.  163,  and  a 
view  in  perspective  would  resemble 
Fig.  164.  The  collar  is  also  very 
useful  whenever  the  root  and  crown 
are  not  flush  and  smooth  at  every 
point,  as,  if  possible,  they  should  always  be  made. 

In  all  cases  it  is  of  great  importance  that  the  root  should 


THK    TARMLV    BROWN    CROWN. 


18I 


be  thoroughly  dried  with  alcohol,  or  ether  and  hot  air,  in 
order  that  the  cement  or  gutta-percha  may  if  possible  adhere 
to   the  walls  of  the  root  to  exclude  moisture  and  insure  the 


Fic;.  165. 


Fig.  166.     Fir,.  167.     Fk;.  168.  Fi<;.  169. 


stabilit}'  of  the  crown  ;   the  stiff  post  of 
w  hicii  will  successfully  resist  any  normal 
.,^      strain,  as  is  made  obvious  by  the  enlarged 
II  \  views  which  in  Fig.  165  exhibit  the  struc- 
I  ture  and  relative  capacity  for  resistance 
/  inherent  in  this  form  of  post.* 
/       The  Parmly  Brown  Crown. — Fig. 
169  is  a  lateral  view  of  a  porcelain  crown 
with  a  platino-iridium  pin  baked  in  posi- 
tion.    The  pin  has  great  strength  at  the 
neck  of  the  tooth,  where  the  strain  is 
greatest,  the  porcelain  of  the  tooth  ex- 
tending  upon  the   pin,  to   increase  the 
strength. 

Fig.  168  is  a  front  view  of  the  same 
crown,  showing  by  dotted  lines  the  form 
which  the  metal  occupies  in  the  crown 
to  increase  the  strength  of  the  attachment  and  prevent  the 
pill  from  approaching  the  surface  in  thin  teeth. 

Fig.  167  is  a  view  of  the  two-pin  bicuspid  crown,  which 
affords  a  pin  for  each  root  of  a  two-rooted  bicuspid,  the  staple 
form  of  the  pin  shown,  by  dotted  lines,  being  a  feature  of 
strength. 


*  Cosmos,  xxvui,  500. 


l82 


OPERATIVE    DENTISTRY. 


Fig.  1 66  is  a  view  of  a  bicuspid  crown  with  the  two  pins 
pressed  together,  making  a  single  pin  for  the  one  root.  The 
double  pin  in  the  bicuspid  crowns  prevents  the  loosening  of 
these  teeth  by  the  rotary  movements  of  mastication,  which,  by 
means  of  the  two  cusps  exert  such  leverage  as  to  turn  and 
break  down  the  ordinary  crown  where  only  one  pin  is  used."  * 

The  Collar  Crown. — "  The  process  to  be  described  reduces 
destruction  of  tooth-substance  to  the  minimum.  Instead  of 
cutting  the  palatine  wall  of  the  tooth  down  to  the  gum-margin, 
the  greater  portion  of  it  is  carefully  conserved,  its  presence, 
while  not  indispensable  to  a  successful  result,  being  in  the 
highest  degree  desirable.     How  much  of  this  portion  of  the 


Fig.  170. 


Fig.  lyr. 


tooth  can  be  retained  will  depend  upon  the  nature  of  the 
occlusion. 

"  In  Fig.  170  the  dotted  line  from  C  to  D  represents  the 
point  to  which  the  tooth  is  cut  away  in  the  older  methods  of 
'  pivoting  ;'  the  dotted  line  from  A  to  B,  the  line  of  abscission 
practiced  by  the  writer. 

"As  will  be  seen  by  reference  to  Fig.  171,  the  face  of  the 
tooth  thus  prepared  presents  a  gradual  slope  from  the  palatal 
surface  to  the  labio-cervical  margin.  At  the  latter  margin  the 
root  should  be  cut  down  with  suitable  burs,  etc.,  to  a  point  a 
little  beneath  the  edge  of  the  gum,  in  order  that  the  porcelain 


*  Cosmos,  xxvHi,  583. 


THE    COLLAR    CROWN.  I  83 

tooth  in  front  may  pass  up  under  the  gum-mar<^in  and  tlie 
joint  between  root  and  tooth  be  concealed.  At  this  point 
tooth-substance  may  be  sacrificed,  as  it  does  not  materially 
diminish  the  strength  of  the  root. 

"  The  several  parts  employed  in  making  the  collar  crown  are 
a  plain-plate  porcelain  tooth  or  facing,  a  platinum-iridium 
retaining-pin,  and  a  backing,  base-plate  and  collar,  made  either 
of  platinum,  pure  gold,  or  twenty-two  carat  gold,  either  metal 
being  made  in  thickness  about  No.  30,  American  gauge. 
When  j)latinum  is  used  coin  gold  or  twenty-carat  gold,  alloyed 
with  copper  or  silver  only,  should  be  employed  as  a  solder 
and  covering.  Twenty- carat  gold  may  be  used  as  a  solder 
when  pure  gold  is  employed,  while  eighteen-carat  gold  will 
solder  the  twenty -two-carat  plate. 

"  In  shaping  the  pulp-canal  for  the  reception  of  the  rctain- 
ing-pin,  care  should  be  taken  not  to  weaken  the  root  by  an 
unnecessary  enlargement  of  the  caliber  of  the  canal.  The 
platinum-iridium  pin  need  not  be  more  than  No.  14,  American 
gauge,  in  thickness  at  its  point  of  greatest  diameter  near  the 
free  surface  of  the  root,  where  all  the  strain,  if  an)',  falls  : 
from  this  point  it  should  be  made  a  gentla  taper  correspond- 
ing to  the  natural  shape  of  the  space  it  is  to  occupy.  Half 
an  inch  in  length  is  ample  ;  even  less  will  serve. 

"The  retaining-pin  being  shaped  and  adjusted  in  the  root, 
care  being  taken  to  leave  an  excess  in  length  at  the  free  end 
for  convenience  in  subsequent  manipulations,  the  next  step  in 
the  process  is  the  making  of  the  base-plate  and  its  attachment 
to  the  pin.  A  strip  of  platinum  or  gold  of  suitable  size  is 
pressed  upon  the  face  of  the  root  with  broad-pointed,  serrated 
instruments  until  it  is  in  close  adaptation  to  the  surface  at 
every  point.  This  base-plate  is  allowed  to  project  beyond  and 
o^>.'crha)ig\}[\^  palatine  portion  of  the  root,  but  should  not  come 
quite  to  the  labial  edge. 

"  Adaptation  being  secured,  an  opening  is  made  in  the  base- 
plate where  it  covers  the  pulp-canal,  through  which  opening 
the  retaining-pin  may  be  pressed  up  into  position  in  the  root. 


184  OPERATIVE    DENTISTRY. 

Pin  and  base-plate  are  then  removed  from  the  mouth,  dried 
and  cemented  with  a  brittle  resinous  cement,  and  then,  while 
the  cement  is  still  plastic  and  yielding  from  heat,  placed  again 
in  position  in  and  upon  the  tooth,  and  perfect  adaptation 
secured.  Then,  while  still  in  position  in  the  mouth,  throw 
upon  the  cement  a  stream  of  very  cold  water,  so  that  it  may 
be  made  brittle  and  incapable  of  bending.  Then  remove  from 
the  mouth  and  invest  in  a  mixture  of  equal  parts  of  plaster 
and  pulverized  marble,  with  enough  water  to  make  a  thick 
paste.  After  this  investment  has  set,  solder  the  retaining-pin 
and  the  base-plate  together. 

"  To  make  the  collar,  a  somewhat  crescent-shaped  piece  of 
platinum  or  gold  of  suitable  size  is  prepared  and  pressed  into 
shape  upon  the  palatine  and  palato-proximal  face  of  the  tooth  ; 
little  slits  may  be  cut  in  the  collar  with  a  delicate  pair  of 
scissors,  to  make  easier  this  adaptation ;  care  should  be  taken 
not  to  push  the  collar  up  under  the  gum  at  any  point,  pro- 
vided the  palatine  wall  of  the  tooth,  which  had  been  allowed 
to  remain  standing  is  at  all  ample  in  height — say  one-tenth  of 
an  inch  ;  if  less  than  this  the  collar  may  pass  under  the  gum 
for  a  short  distanoe,  as  will  be  shown  subsequently.  In  the 
average  case  this  collar  will  not  quite  one-half  encircle  the 
tooth. 

Fig.  172  shows  the  collar  curved  to  the  outline  of  the  gum- 
margin  and  shaped  to  the  contour  of  the  palato-proximal  wall 
of  the  tooth.  At  G  are  the  slits  cut  in  the  platinum  to  allow 
overlapping  in  shaping  to  contour. 

"  In  order  to  strengthen  the  collar  and  facilitate  its  attach- 
ment to  the  base-plate,  cut  a  series  of  slits  in  that  portion  of 
the  base-plate  which  has  been  made  to  project  beyond  the 
palatine  wall  of  the  tooth,  and  the  base-plate,  with  its  now 
attached  pin,  being  placed  with  the  collar  in  position  in  and 
upon  the  tooth,  the  little  strips  of  metal  into  which  the  over- 
hanging edge  of  the  base-plate  has  been  cut  are  pressed,  one 
after  the  other,  down  upon  the  collar,  and  carefully  moulded 
to   its  surface,  so  that  the  collar  will  no  longer  consist  of  a 


THE    COLLAR    CROWN. 


185 


single    thickness  of  metal,  but  will    be  reinforced    by  these 
additional  thicknesses  of  base-plate  thus  pressed  upon  it. 

"  Fi^.  173  shows  this  cjuite  perfectly:  H  is  the  free  end  of 
the  retaining  pin  which  is  to  be  cut  off  when  the  porcelain 
tooth  is  mounted.  I  is  the  base-plate,  with  its  overhanging 
palatine  margin  cut  into  strips,  J,  which  are  being  pressed 
down  upon  the  collar,  F,  by  the  broad-surfaced  and  serrated 
instrument,  K.  This  being  accomplished,  remove  the  several 
pieces  from  the  mouth,  carefully  cement  the  collar  in  its  proper 
position  relative  to  the  base-plate,  which  will  now  form  a  sort 
of  matrix  for  it;  again  place  in  the  mouth,  readjust,  harden 
the  cement,  remove  from  the  mouth,  invest  as  before,  and 
solder  the  collar  and  base-plate  together,  using  a  considerable 


Fig.  173. 


Fig.  172. 


Fig.  J74. 


excess  of  solder  for  covering,  so  that  the  collar  may  be  still 
further  strengthened  and  its  surface  be  made  uniform. 

"  In  cementing  the  collar  to  the  base-plate,  one  precaution 
is  imperative — namely,  not  to  allow  a  film  of  cement  to  get 
between  the  collar  and  the  tooth.  If  this  is  done  and  the 
investment  poured  in  upon  this  film  of  cement,  the  latter  will 
immediately  burn  out  as  soon  as  heat  is  applied,  leaving  a 
space  between  the  collar  and  the  investment  into  which  the 
gold  solder  will  flow,  and  thus  interfere  with  that  perfect 
adaptation  of  the  appliance  to  the  tooth  which  is  necessar)'  to 
a  successful  result. 

"  The  mounting  of  the  facing  next  demands  attention.  As 
13 


I  86  OPERATIVE    DENTISTRY. 

already  stated,  a  plain-plate  porcelain  tooth  is  used.  This 
.must  have  what  are  technically  known  as  cross-pins ;  that  is, 
pins  placed  at  right-angles  with  the  long  axis  of  the  tooth. 
They  must  also  be  placed  well  up  toward  the  cutting  edge. 
If  they  are  too  near  the  neck,  they  will  inevitably  be  cut  out 
in  fitting  the  tooth  to  the  slope  of  the  base-plate  on  which  it 
must  be  mounted. 

"  Fig.  174  shows  the  form  of  the  facing,  and  indicates  the 
slope  given  it  in  fitting.  The  fitting  process  does  not  differ 
from  that  ordinarily  employed  with  porcelain  teeth ;  an 
impression  may  be  taken  and  the  work  done  on  a  cast,  or  the 
facing  may  be  fitted  to  the  mouth.  In  either  case  it  is  in  the 
mouth  that  the  finer  and  final  adjustments  as  to  height,  con- 
tour, alignment,  etc.,  must  be  perfected. 

"  This  being  done  and  the  facing  backed,  tooth  and  breast- 
plate are  cemented  together,  restored  to  the  mouth,  finally 
adjusted,  removed,  and  soldered  as  before,  as  much  gold  being 
flowed  into  the  angle  between  the  backing  and  the  base-plate 
as  occlusion  will  permit. 

"  This  artificial  crown  being  properly  finished  and  cemented 
into  position  in  and  upon  the  tooth,  makes  what  the  writer, 
from  several  years'  experience  in  its  use  in  a  large  number  of 
cases,  has  found  to  be  an  appliance  which  will  remain  for  an 
indefinite  period  without  the  slightest  deviation  from  position 
and  alignment,  and  which,  in  many  respects,  is  almost  as. 
strong  as  the  natural  tooth,  because  its  point  of  greatest 
resistance  to  pressure  is  placed  where  Nature  anchors  her 
enamel  walls — namely,  upon  the  outside  and  not  upon  the 
inside  of  the  walls  of  dentine,  so  that  in  the  act  of  occlusion 
the  force  applied  by  the  lower  incisors  as  they  come  up  in 
position  inside  the  upper  incisors  falls  upon  the  ivJiole  thick- 
ness of  the  root  through  the  collar,  and  not  upon  less  than  half 
its  thickness  through  a  centrally-anchored  pin — a  pin,  too, 
prolonged  into  a  lever  of  enormous  power  by  jts  attachment 
to  the  porcelain  tooth. 

"  In  this  respect  there  is  a  manifest  weakness  in  all  methods 


THE    COLLAR    CROWN. 


187 


of  mounting  artificial  crowns  which  depend  for  their  stabihty 
solely  upon  the  central  pin.  Ultimate  failure  throu<^h  splitting 
of  the  root  is  the  frequent  result,  and  the  larger  and  stronger 
and  more  deeply  anchored  the  pin  the  more  certain  this  result, 
because  a  large  pin  necessitates  a  large  opening  for  its  re- 
ception, and  a  corresponding  weakening  of  the  root,  upon 
which  the  strain  must  ultimately  fall  :  the  lever  is  strengthened 
and  the  point  of  resistance  weakened. 

"  The  only  safety  for  the  usual  form  of  '  pivot-tooth  '  is, 
either  that  the  occlusion  shall  be  slight,  the  root  very  strong, 
or  the  '  pi\'ot  '  very  flexible  or  elastic.  This  elasticity  of  the 
old  hickory  *  pivot '  was  one  of  its  chief  excellences  ;  roots 
were  much  less  likely  to  split  than  with  a  rigid,  unyielding 
metallic  pin.  In  cuspids  or  incisors,  however,  metallic  pins, 
unless  enormously  large  or  thickly  packed  around  with 
amalgam,  will  very  often  bend  outward,  thus  allowing  a  slight 
displacement  forward  of  the  artificial  crown,  and  to  that  ex- 
tent relieving  the  root  from  strain. 

"Fig.  175  gives  a  sectional  view  of  the  collar-crown  in  posi- 
tion, the  lower  incisor  being  in  occlusion.    L  is  the 

.  .  .  .  Fig.  175. 

porcelain  facing.  H  is  the  pin  attached  to  I,  the 
base-plate.  M  is  the  backing  and  solder.  N  is 
the  lower  incisor,  and  F  the  collar.  It  is  clearly 
evident  that  here  the  force  of  occlusion  falls  upon 
the  palatine  wall  of  Ijie  natural  tooth  at  O, 
through  the  collar  F,  and  not  upon  the  pin  at 
the  point  of  its  attachment  to  the  base-plate  H, 
and  through  the  pin  upon  the  thin  outer  shell  of 
the  root. 

"  In  cases  frequently  met  with,  where  the  en- 
tire crown  of  the  tooth  has  been  removed,  the 
collar,  as  before  described,  can  be  adapted  to 
the  palatine  face  of  the  root,  provided  the  latter 
be  not  decayed  away  up  to  the  alveolar  margin. 
Usually,  however,  there  is  a  considerable  space  between  the 


I  88  OPERATIVE    DENTISTRY. 

free  edge  of  the  root  and  the  alveolus,  and  here,  running  up 
to  the  alveolus,  the  collar  must  be  placed. 

"  The  dotted  line  E  in  Fig.  171,  p.  182,  indicates  a  collar  so 
placed.  All  the  steps  in  the  process  are  essentially  the  same 
as  before  described.  Adapting  the  collar  to  the  surface  of  the 
root  beneath  the  gum  is  somewhat  painful,  but  not  excessively 
so,  and  in  the  wearing  the  irritation  caused  by  its  presence  is 
very  slight  and  transient  in  character,  assuming,  of  course, 
that  care  has  been  taken  to  leave  upon  it  a  smooth,  thin,  and 
well-polished  edge. 

"  The  objection  may  be  urged  that  this  form  of  crown  re- 
sists pressure  only  in  one  direction,  from  within  outward,  and 
does  not  provide  for  lateral  pressure  or  pressure  from  the 
front.  As  a  rule,  the  latter  can  occur  with  any  force  only 
as  the  result  of  accident,  while  if  the  crowned  tooth  is 
in  normal  relation  with  its  fellows,  and  the  artificial  crown 
be  closely  fitted  between  them,  they  will  fully  sustain  lateral 
force. 

"  When  such  lateral  support  is  wanting,  through  isolation  of 
the  tooth,  the  collar  must  be  extended  into  a  ring  or  ferrule 
completely  encircling  and  grasping  the  root,  and  thus  affording 
support  on  all  sides.  The  ring,  however,  is  more  troublesome 
to  make  and  more  painful  to  apply,  and  generally  shows  a  line 
of  gold  in  front.  In  the  average  case  the  simple  collar  gives 
all  requisite  strength. 

"  In  mounting  crowns  upon  bicuspid  and  molar  roots,  how- 
ever, the  ferrule  principle  is  often  essential  to  stability; 
especially  is  this  true  of  lower  bicuspids  and  molars  ;  as  here 
the  forces  applied  in  mastication  are  as  erratic  in  direction  as 
they  are  powerful  in  character,  and  the  root  must  be  guarded 
at  every  point  against  their  violence. 

"  In  fixing  in  position  the  artificial  croMais  just  described, 
the  writer  prefers  to  use  a  gutta-percha  cement,  adhesive  in 
character,  which  will  not  strip  from  the  pin  when  the  crown  is 
forced  into  position. 


THE    COLLAR    CROWN.  1 89 

"  The  apical  foramen  is  closed,  the  pulp-canal  ^n-oovcd 
and  thoroui^hh'  dried,  the  central  pin  is  barbed,  and  the 
pin  and  inside  of  the  collar  and  under  surface  of  the  base- 
plate are  thickly  coated  with  gutta-percha ;  the  entire 
appliance  is  then  heated  to  a  temperature  sufficient  to 
thoroughly  soften  the  gutta-percha,  and  firmly  pressed  up 
into  position ;  the  excess  of  gutta-percha  will  ooze  out 
at  all  free  margins,  and  may  be  subsequently  removed  with 
suitable  instruments. 

"  A  good  gutta-percha  cement  will  hold  firmly  in  a  great 
majority  of  cases,  but  when,  as  in  a  small  lateral  incisor,  the 
retaining-pin  is  necessarily  small  and  short,  and  the  collar  not 
as  ample  as  could  be  desired,  an  oxychloride  or  oxy- 
phosphate  cement,  mixed  thin,  will  be  found  to  give  greater 
stability.  When  these  cements  are  used,  however,  it  will 
be  found  very  difficult  to  detach  the  artificial  crown  from 
the  root,  should  it  for  any  reason  become  necessary  to  do 
so ;  whereas,  a  little  heat  will  quickly  soften  a  gutta-percha 
packing  and  permit  the  entire  appliance  to  be  withdrawn 
without  difficulty. 

"  There  are  various  methods  of  mounting  artificial  plate  teeth 
in  natural  roots,  in  which  the  dowels  are  used  simply  as  a  means 
of  holding  the  tooth  in  place  while  gold  or  amalgam  is  packed 
into  the  root  and  built  up  to  form  the  palatal  surface  of  the 
fixture,  this  being  mainly  relied  upon  to  support  the  tooth  in 
position. 

"  These  operations,  especially  if  done  with  gold,  are  exceed- 
ingly difficult  and  tedious.  When  we  consider  this  in  connec- 
tion with  the  fact  that  in  case  the  porcelain  crown  is  accident- 
ally fractured,  there  is  no  way  of  repairing  the  injury  without 
destroying  all  that  has  been  done,  and  redoing  it,  I  consider 
them  of  doubtful  value. 

"  The  probability  of  accident  is  always  present ;  I  there- 
fore regard  facility  of  repair  as  practically  an  important 
consideration     in     estimating    the     relative    value     of    any 


1 90 


OPERATIVE    DENTISTRY. 


method  of  replacing,  by  artificial  substitutes,  these  im- 
portant organs."  * 

The  Bonwill  Crown. — "  This  consists  of  an  all  porcelain 
crown  with  a  hole  through  it  and  countersunk  in  the  outer 
surface,  Fig.  178  and  179  showing  the  molars. 

"  Fig.  176.  Sectional  view  of  an  incisor  crown  as  now 
made,  from  mesial  side,  showing  the  under-cut  at  the  point 
opening  on  palatal  surface,  the  conical  base  and  the  opening 
from  the  same  to  the  retaining  grooves,  with  the  exact 
relations. 

"  Fig.  177.  Palatal  view  of  the  same  tooth  :  a  is  the  external 
opening  for  egress  of  alloy  and  for  packing  around  the  piri  ;  the 
dotted  hnes  around  a  show  the  recess  or  under-cuts  on  the 
mesial  and  distal  sides  and  near  the  point,  for  retaining  the 
crown,  and  its  relation  with  the  conical  base. 


Fig. 179. 


"  Fig.  178.  Grinding-surface  view  of  a  superior  molar,  with 
the  countersunk  pin  holes  on  the  buccal  and  palatal  sides. 

"Fig.  179.  Same  view  of  an  inferior  molar  with  the  pin- 
holes on  the  mesial  and  distal  sides. 

"  Fig.  180  and  181.  Sectional  view  of  a  molar  and  bicuspid 
crown,  showing  the  countersinks  and  their  relations  with  the 
conical  base. 

"Fig.  182.  Sectional  view  of  an  incisor  root,  showing  the 
retaining  cuts  made  by  the  wheel  bur  shown  in  Fig.  189. 

"  Fig.  183.  End  view  of  a  canal  prepared  for  the  improved 
combination  metal-pin. 


*"  Am.  Syst.Dent.,"  11,  807. 


THE    DONWILL    CROWN. 


191 


"  I'i^.  184.  End  view  of  same  canal  as  in  Fi^.  183,  prepared 
for  a  triangular  pin,  showing  how  nuich  more  of  the  mesial 
and  distal  surfaces  have  been  cut  away  from  it  than  in  Fi^.  183 
for  the  improved  pin. 

"  Fi<^.  185.  Sectional  view  of  an  incisor  crown  and  root, 
w  ith  the  improved  pin  in  its  relative  position  to  each,  with  the 
depressions  made  by  wheel  bur. 

"  Fig.  186.  Sectional  view  of  a  superior  molar,  with  the 
large  angular  pin  in  palatal  root  and  two  square  pins  in  the 
buccal  roots,  one  being  shorter  and  not  passing  through  the 
crown. 

"Fig.  187.  Block  of  a  molar  and  bicuspid,  showing  the 
countersunk   holes  for  pins  in  the  molar  and  the  hole  in  the 


Fig.  183. 

©c 


Fig-  184 


Fig.  185.  Fig.  186. 


Fig.  187. 


Fig.  188.     Fig. 18 


mesial  side  of  the  second  bicuspid  where  a  pin  is  alloyed  in 
and  set  into  a  decayed  cavity  in  the  distal  surface  of  the  first 
bicuspid,  being  held  upon  the  molar  roots  and  attached  to  the 
bicuspid  by  the  alloy. 

"  Fig.  188.  Side  and  end  view  of  the  largest  size  angular 
combination  metal  pin  with  the  stamped  serrations.  The 
square  pins  are  without  serrations  and  double  pointed,  made 
of  same  metal  and  of  equal  thickness  throughout.  All  the 
pins  as  now  made  are  without  serrations  and  of  double  thick- 
ness. 

"Fig.  189.  The  smallest-sized  wheel-bur  for  grooving  the 
canals  for  anchoring  the  pin  and  alloy.  No  need  of  more 
than  one  wheel  on  each  shaft. 


192  OPERATIVE    DENTISTRY. 

"  The  pins  are  made  of  platinum-iridium  alloy,  and  barbed, 
to  hold  more  firmly. 

"  Later  pins  of  hard  metal,  an  alloy  which  will  amalgamate. 
These  do  not  need  to  be  barbed,  and  can  be  pulled  out  more 
easily,  if  need  be. 

"  The  natural  tooth  is  cut  and  ground  off  a  little  below  the 
margin  of  the  gum.  The  porcelain  crown  is  then  ground  to 
fit  the  surface  of  the  root  and  the  occlusion  of  the  opposing 
tooth. 

"  The  root  canal  is  enlarged,  and  the  pin  of  proper  size 
adjusted  to  it. 

"  The  pin  is  cut  the  right  length  and  bent,  if  need  be,  to  sup- 
port the  crown  in  position.  The  walls  of  the  canal  are  grooved 
with  a  wheel  bur,  as  shown  in  Fig.  182. 

"  To  set  the  crown  the  canal  is  partially  filled  with  amalgam 
and  the  pin  forced  to  place  with  a  pair  of  pliers ;  then  addi- 
tional amalgam  is  packed  around  the  pin  until  the  canal  is 
full.  Then  cover  the  pin  with  soft  gutta  percha  to  protect  the 
tongue,  and  dismiss  the  patient. 

"  At  a  subsequent  sitting  the  crown  may  be  set,  placing  some 
amalgam  on  the  root  and  forcing  the  crown  to  place,  and 
packing  additional  amalgam  around  the  pin  through  the 
hole  in  the  crown,  and  filling  the  countersink.  Smooth  off 
the  amalgam  at  the  joint  under  the  gum,  leaving  it  just 
flush. 

"  A  quick-setting  amalgam  made  purposely  for  it  is  the  most 
suitable,  and  should  be  prepared  quite  soft. 

"  The  color  of  the  amalgam  darkens  the  tooth  crown  some- 
what, and  often  produces  a  blue  line  at  the  joint  under  the 
gum. 

"  The  use  of  oxyphosphate  cement  avoids  this,  and  also  sets 
the  crown  very  firmly.  In  case  the  root  is  frail,  a  band  may 
be  fitted  and  put  on,  and  the  crown  fitted  into  it.  It,  in  such 
cases,  adds  greatly  to  its  strength."  * 

*  "Am.  Syst.  Dent.,"  n,  813. 


THE    HOW    CROWN.  1 93 

Figs.  :qo,  191,  k  192    Fig.  193.     Fig.  194.     Fig.  195.  Fig.  196.      Fi(;s.  197,  198,  199,  k  joj. 


iJ 


IJ 


an  1 


The  How  Crown. — The  How  artificial  tooth- 
crown  is  described  by  Dr.  W.  Storer  How  as  fol- 
lows : — 

"  I.  When  the  root  is  in  proper  condition  for 
mounting,  measure  the  depth  of  the  canal  by  means 
of  the  canal  plugger  (Fig.  190)  and  its  flexible 
gauge  (Fig.  192),  and  fill  the  canal  at  and  a  short 
distance  from  the  apex  of  the  root,  keeping  the 
gauge  at  position  to  show  the  full  length  of  the 
canal,  and  also  the  distance  to  which  it  has  been 
filled. 

"  2.  Cut  off  the  root-crown  with  excising  forceps, 
No.  31,  and  a  round  file,  down  to  the  gum  margin, 
and,  with  barrel  bur  No.  241,  cut  the  labial  part  of 
the  root  fairly  under  the  gum  without  wounding  it. 

"  3.  Set  gauge  (Fig.  192)  on  a  Gates  drill  (Fig.  191) 
to  one-half  the  gauged  depth  of  the  canal,  and  drill 
to  that  depth. 

"  4.  Set  the  twist  drill  (Fig.  195)  in  its  chuck  (Fig. 
199)  to  project  the  same  length  as  the  Gates  drill, 
and  turning  the  chuck  with  thumb  and  finger,  drill 
the  root  to  exactly  that  depth. 

"  5.  Enlarge  the  mouth  of  canal  one-sixteenth  of 
nch  deep  all  around  to  near  the  margin  of  the  root,  using 


194 


OPERATIVE    DENTISTRY. 


square-end  fissure-bur  No.  59,  and  then  with  oval,  No.  94, 
under-cut  a  groove  at  sides  and  hngually,  as  shown  in  Fig. 
196. 

"  6.  If  the  rubber  dam  is  to  be  used  for  a  gold  or  plastic 
backing,  put  it  now  over  the  root  with  Hunter's  root  clamp, 
also  over  the  adjacent  teeth,  and  thoroughly  dry  the  canal. 

"  7.  Set  the  tap  (Fig.  197)  in  its  chuck  (Fig.  200)  a  trifle  less 
in  length  than  the  drill,  and  carefully  tap  to  the  gauge  depth. 

"  8.  Insert  the  post  in  its  chuck  (Fig.  198)  to  the  exact  gauge 
of  the  tap,  and  turn   the  thumb-screw  down  hard  on  the  end 


Fig.  201. 


Fig.  204. 


Fig.  207. 


of  the  post ;  then  screw  the  post  into  the  root,  release  the 
thumb-screw,  unscrew  the  chuck  a  half  turn,  bend  the  post 
until  the  chuck  stands  in  centre  line  with  the  adjoining  teeth, 
and  unscrew  the  chuck.  ' 

"9.  Slit  the  rubber  back  from  adjacent  teeth,  tucking  the 
flaps  out  of  the  way,  so  that  occlusion  may  be  tried,  and  the 
post  excised  and  ground  off  until  the  teeth  close  clear  of  the 
post. 

"  10.  Try  the  crown  on  the  post,  and  with  an  F  disk,  dry, 


THE    HOW    CROWN.  1 95 

grind  the  rib  between  the  neck  pins  until  the  crown  is  labially 
flush  with  the  root  margin,  cutting  a  Httle  at  a  time  until 
exactly  flush. 

"II.  Take  the  crown  and  place  the  mandrel  (Fig.  201) 
between  the  pins  just  as  the  post  is  to  be,  and  with  the  pliers 
(Fig.  202)  bend  the  pins  carefully  over  the  mandrel,  cutting 
off"  the  pins  if  too  long  to  be  pinched  in  on  the  mandrel  at 
the  sides,  observing  that  the  pin  nearest  the  cutting-edge  is 
first  to  be  bent  (Fig.  204),  and  the  opposite  pin  bent  below  it 
on  the  mandrel,  and  so  with  the  others  (Fig.  205). 

"  1 2.  Slip  the  crown  over  the  post,  try  occlusion,  and  with 
the  post-chuck  bend  the  post  until  the  crown  is  properly 
aligned  with  the  teeth  ;  then  with  a  stump  corundum  wheel 
No.  3  grind  the  neck  of  the  crown  to  a  close  labial  fit  with  the 
root,  fitting  only  the  portion  to  be  concealed  by  the  gum, 
leaving  narrow  gaps  at  the  sides  to  be  filled  by  the  backing 
between  crown  and  root  (Fig.  206). 

"  1 3.  Grind  cutting-edge  for  relation  to  the  other  teeth,  being 
sure  that  opposing  tooth  does  not  strike  crown,  or  post,  or 
pins. 

"  14.  Fix  crown  on  post  by  pinching  the  pins  into  the  screw- 
threads  of  the  post  with  special  pliers.     (Fig.  202  or  203.) 

"  15.  Finally,  pack  the  backing  of  gold,  or  cement,  or  amal- 
gam, or — for  temporary  backing  while  treating  abscess — gutta- 
percha, into  all  the  crevices  around  the  post  and  behind  and 
under  the  pins,  and  between  the  crown  and  the  root ;  contour 
and  finish  thoroughly,  so  that  no  ledge  or  other  imperfection 
can  be  found. 

"  Fig.  207  shows  in  vertical  mid-section  an  incisor  crown 
mounted  ;  the  blackened  portions  of  the  backing  defining  the 
locking-hold  of  the  backing  on  the  post,  the  crown-pins,  and 
the  root  recess. 

"  Fig,  208  shows  in  perspective  a  cuspid  crown  ready  to  be 
slipped  over  its  post,  and  also  a  cuspid  crown  ready  for  its 
post  in  the  bicuspid  root,  which  has  its  lingual  cusp  remaining. 


196 


OPERATIVE    DENTISTRY. 


and  Fig.  209  shows  the  crowns  on  their  posts  awaiting  the 
contour-backing. 

"  In  mounting  a  crown  on  the  bicuspid  root  (Fig.  208),  the 
chucks  will  not  pass  the  natural  cusp,  and  hence  both  the  drill 
and  the  tap  must  project  the  cusp's  length  in  addition  to  the 
gauge  length.  Observe  also  if  the  space  between  the  tap  and  the 
cusp  is  wider  than  the  thickness  of  a  crown-pin,  and  if  not  cut 
the  cusp  vertically  with  a  large  fissure-bur,  so  that  the  space 
shall  be  wide  enough  before  setting  the  post,  else  the  bent 
pins  will  not  pass  between  the  post  and  cusp.  Grind  the  rib — 
see  step  10 — quite  down  to  the  floor  of  the  crown;  take  steps 
II,  12  and  13,  and  if  the  occlusion  necessitates  grinding  the 


Fig.  208. 


Fig.  209. 


crown  so  as  to  destroy  one  pair  of  pins,  invest  the  crown,  and 
solder  the  pins  at  the  lap,  taking  step  15  for  completion. 

"  When  it  is  desired  to  contour  the  backing  of  a  cuspid  crown 
to  form  an  inner  cusp,  or  to  adapt  a  cuspid  or  incisor  crown 
for  masticating  uses,  the  pins  may  be  twisted  together  over 
the  mandrel,  and  again  twisted  tightly  over  the  post,  as  in 
Fig.  210;  but  in  some  cases  it  maybe  better  to  bend  the 
neck-pins,  as  in  Fig.  21 1,  instead  of  twisting  them.  In  all 
cases  the  bent  pins  are  to  be  pinched  quite  hard  over  the 
mandrel  and  post,  so  that  the  serrations  of  the  pliers  will 
roughen  the  pins,  to  prevent  their  being  pulled  through  the 
backing,  which  should  also  be  condensed  around  the  pins 
and  po.st. 

"  If  the   root  is  not  ready  for  permanent  mounting,  use  a 


THE    HOW    CROWN. 


197 


tubular  post,  or  in  the  absence  of  a  threaded  tube,  take  the 
successive  steps  up  to  13;  then  back  temporarily  with  wax, 
rubber,  or  gutta-percha,  awaiting  the  next  sitting,  when  the 
crown  may  be  taken  off,  the  post  unscrewed,  and  the  remedy 
applied.  Thus  the  root  may  be  alternately  medicated  and 
mounted  until  ready  for  the  permanent  crown. 

"  When  the  root  is  much  decayed,  the  bottom  of  the  cone- 
shaped  cavity  may  be  drilled  and  tapped  to  the  depth  of  a 
sixteenth  of  an  inch,  and  the  post,  thus  anchored,  may  be 
further  secured  by  cement  in  the  grooved  walls  of  the  cavity 
and  around  the  post  (Fig.  212). 

"  TheSe  crowns  afford  unusual  facility  for  mounting  by  any 


Fig. 


Fig.  211 


Fig.  212. 


Fig.  213. 


of  the  well-known  methods  of  inserting  the  post,  after  solder- 
ing it  to  the  crown.  They  are  also  adapted  for  use  in  cellu- 
loid and  rubber  work,  especially  in  cases  of  single  teeth.  The 
several  long  pins,  having  their  ends  bent  with  pliers  at  a  sharp 
angle  (Fig.  213),  may  be  so  arranged  as  to  both  strengthen 
the  shank  of  the  plate  and  hold  the  crown  very  firmly  in 
position. 

"  The  screw-posts  are  made  of  crown  metal,  an  alloy  devised 
for  the  purpose  in  order  to  obtain  a  stiff  post  that  will  permit 
the  cutting  of  the  peculiar  and  extremely  accurate  thread 
formed  upon  it,  and  which  will  not  amalgamate  or  be  other- 
wise affected  by  any  backing-material  that  may  be  used.     Of 


198 


OPERATIVE    DENTISTRY. 


course  platinum  or  platinum  alloyed  with  iridium  may  be 
employed  for  posts,  but  the  crown  metal  is  in  every  way 
superior. 

"  There  are  some  cases  of  a  class  which  has  hitherto  pre- 
sented difficulties  that  may  not  be  easily  overcome  by  grind- 
ing the  post  flat  on  the  crown  side  after  it  has  been  set  and 
bent  in  the  root  (Fig.  214),  so  as  to  be  clear  of  the  occluding 
tooth  ;  and  then  the  crown-pins  may  be  bent  over  the  reduced 
post,  the  crown  fitted  and  ground  to  clear  the  opposing  tooth 
(Fig.  215),  and  the  backing  added. 

"A  similar  case,  in  which  the  opposing  tooth  and  a  proper 


Fig.  214.  Fig.  215.  Fig.  216. 


Fig.  217. 


Fig.  21 


alignment  require  an  oblique  bending  of  the  pins,  is  seen  in 
Fig.  216,  while  the  reverse  arrangement  of  parts  is  shown  in 
Fig.  217.  The  crown  is  thus  seen  to  be  adapted  to  a  wide 
range  of  adjustments  because  its  point  of  contact  with  the  root 
is  at  the  labial  portion  of  the  neck,  on  which  as  on  a  hinge  the 
crown  may  be  swung  out  or  in  (Fig.  218,  dotted  lines),  over 
an  arc  of  at  least  sixty  degrees,  at  any  point  of  which  it  may 
be  quickly  and  firmly  fixed.  The  labio-cervical  junction  is 
made  just  under  the  gingival  margin,  and  I  usually  interpose 
a  thin  layer  of  cement,  amalgam,  or  gutta-percha,  or  a  narrow 
ribbon  or  several  large  blocks  of  soft  gold;  the  joint  always 


I5ALDWIN  S    CROWN.  I99 

to  be  made  smooth,  and  hid  from  view  under  the  free  margins 
of  the  gums. 

"  The  obviously  great  advantages  of  such  a  plan  led  to  the 
adoption  of  a  single  size  for  post  and  appliances,  but  a  second 
size  has  been  proved  to  be  a  necessity,  and  hence  the  B  size  is 
now  designed  for  superior  centrals,  and  cuspids,  while  the  A 
size  is  used  for  laterals  and  bicuspids,  as  also  for  all  the  inferior 
roots  anterior  to  the  molars.  The  handles  of  the  tap-chucks 
and  post-chucks  are  made  of  small  diameter  to  insure  that  too 
great  force  shall  not  be  used  with  the  thumb  and  finger  in 
turning  in  the  tap  and  the  post;  and  it  is  enjoined  upon  the 
operator  to  remove  the  tap  when  it  begins  to  turn  at  all 
hard,  and  repeat  the  removal  until  it  has  been  easily  turned 
down  to  the  gauge  depth.  The  cuttings  must  then  be  care- 
fully blown  or  wiped  out,  so  that  the  post  may  be  easily  turned 
down  to  the  bottom  of  the  hole  without  risk  of  splitting  the 
root,  as  there  is  danger  of  doing  with  too  great  force  acting 
on  the  debris  as  a  wedge — hence  this  caution  to  employ  only 
a  reasonable  amount  of  force  and  to  do  thorough  work.  The 
disk  for  grinding  the  crown-rib  is  an  essential  part  of  the 
equipment,  and  when  the  engine  is  not  at  hand,  may  be  used 
in  the  lathe  by  means  of  lathe-chuck  No.  8." 

Baldwin's  Crown. — "The  modus  operandi  is  as  follows  : 
Select  a  Logan  crown  slightly  shorter  than  would  be  used  for 
setting  without  a  ferrule.  Countersink,  and  prepare  the  inside 
of  a  root  as  for  a  Bonwill  or  any  ordinary  crown.  If  the  out- 
side of  the  root  at  the  margin  of  the  gum  presents  an  irreg- 
ular surface,  then  with  Dr.  Walter  Starr's  reducers  shape  it 
to  such  a  size  that  the  ferrule  may  be  perfectly  adapted  to  all 
parts.  Then  take  an  impression,  and  produce  in  zinc  or  Bab- 
bitt metal  a  die,  to  form  which  take  a  plaster  model  of  the  root 
end  an  eighth  of  an  inch  long,  and  shellac  it  to  the  point  of  a 
cone,  which  can  be  easily  made  by  turning  down  a  large  spool, 
thus  making  the  deep  mold  in  sand,  into  which  the  metal  is 
poured.  With  this  die  strike  the  gold  (twenty-two  carat,  No. 
30  gauge,  is  most  commonly  in  use)  laid  upon  soft  lead.     A 


200  OPERATIVE    DENTISTRY. 

few  blows  will  produce  a  seamless  and  perfectly-fitting  cover 
and  ferrule.  After  trimming  this  to  fit  the  festoon  of  the  gum, 
drill  in  it  from  the  lower  side  a  hole  for  the  pin  of  the  crown, 
leaving  the  ragged  edge  produced  by  the  drill.  Then  fill  the 
countersunk  portion  in  the  porcelain  crown  with  oxyphos- 
phate  of  zinc,  and  with  the  gold  ferrule  or  cap  in  place  adjust 
the  crown  as  you  would  wish  it  when  completed.  When  the 
oxyphosphate  is  hard,  you  will  find  the  ragged  edge  on  the 
upper  side  of  the  cover  will  materially  aid  in  removing  and 
keeping  the  cap  where  it  belongs.  Unite  the  cover  to  the 
platinum  pin  in  the  crown  with  a  small  amount  of  soft  solder 

Fig.  2ig. 


Fig.  221. 
Fig.  220.  g\ 


— tin  and  lead — using  muriate  of  zinc  as  a  flux,  a  few  blasts 
from  the  blowpipe  being  all  the  heat  required.  Then  fill  the 
root  with  oxyphosphate  and  firmly  press  to  place.  These  caps 
might  be  made  up  at  leisure,  providing  a  few  variations  for 
double  and  single-rooted  teeth.  When  a  case  is  met  that 
you  cannot  fit  from  your  stock,  choose  a  cap  larger  than  the 
end  of  the  root,  and  with  a  single  clip  of  the  shears  cut  to  the 
centre  of  the  cap,  and  with  pliers  spring  together  and  lap  the 
edges  until  the  size  required  is  obtained.  Solder  with  gold 
solder  by  holding  over  the  spirit  lamp  and  proceed  as  before. 
Fig.   219  shows  a  root  cover  and  Logan  crown  ready  to  be 


low's  crown. 


20 1 


assembled  for  the  soldering  of  the  crown-pin  to  the  cover; 
Fig.  220  shows  the  cap  cemented  and  soldered  to  the  crown ; 
and  Fig.  221  the  completely  crowned  root."  * 


Low's  Crown, — In  our  first  cut,  Fig.  222,  we  present  seven 
instruments.    No.  i,  the  smallest,  will  be  used  most  frequently. 


*  Cosmos,  XXIX,  19. 


14 


202  OPERATIVE    DENTISTRY. 

Any  tooth  generally  considered  beyond  restoration  can  be 
crowned  with  this  instrument. 

"  We  now  have  before  us  in  Fig.  223  a  central  incisor  badly 
decayed.  There  is  little  tooth-substance  exposed  below  the 
margin  of  the  gum,  the  little  remaining  being  the  outer  walls. 
The  first  step  to  be  taken  to  place  on  this  root  a  strong  and 
serviceable  crown  is  to  cut  or  grind  even  with  the  gum  what 
tooth-substance  remains.  We  start  off  with  the  supposition 
that  the  root  is  in  a  healthy  condition ;  if  not,  it  must  first  be 
treated  and  made  so,  as  this  is*the  first  consideration  in  the 
final  result  of  a  successful  operation.'  The  next  step  is  to 
select  the  instrument  in  accordance  with  the  size  of  the 
opening  in  the  root  to  be  crowned.  The  larger  the  opening 
in  the  root  the  larger  the  inside  or  centre  cutters  must  be,  and 
the  narrower  the  cutters  that  bevel  and  prepare  the  end  of  the 
root.  The  reason  for  this  is  that  the  space  is  nearly  all  taken 
by  the  inside  cutters  in  order  to  reach  and  cut  away  the 
decayed  tooth-substance,  and  prepare  the  root  to  properly 
receive  the  step-plug  with  bevel  cap  which  covers  the  end. 

"  We  have  seven  sizes  of  instruments,  and  if  the  right  one  is 
selected,  no  tooth-substance  will  be  removed  that  ought  not 
to  be,  cutting,  as  it  does,  the  least  where  the  tooth  is  smallest, 
or,  in  other  words,  we  cut  the  opening  in  the  tooth  tapering 
to  the  shape  of  the  root. 

"  These  cutters  leave  the  root  in  the  shape  of  Fig.  224,  with 
graded  steps. 

"  We  next  select  the  graded  step-plug  seen  in  Fig.  225. 

"  This  is  the  same  size  as  the  instrument,  and  will  perfectly 
fit  the  opening  and  cover  the  end  in  a  beveled  saucer  shape, 
and  by  its  attachment  to  the  inside  step-plug  when  cemented 
make  a  combined  union  of  great  strength,  and  so  made  as  to 
be  impossible  for  the  root  to  split.  Fig.  226  shows  the  step- 
plug  placed  in  position. 

"  After  placing  the  plug  in  position,  an  articulation  of  wax 
and  impression  of  the  space  to  be  supplied  and  of  the  adjoin- 
ing  teeth    are  taken   in    plaster-of-Paris.     Before  taking  the 


LOW  S    CKOWN. 


203 


impression  be  careful  that  the  pin  which  extends  from  the  cap 
of  the  stcp-plui,f  for  purpose  of  removing  is  free  from  all  rough- 
ness (a  roughness  that  is  sometimes  left  in  the  cutting  of  the 
plug),  as  this  is  liable  to  break  the  plaster  when  removing 
the  impression.  I  generall}'  fill  the  step-plug  on  a  slant 
from  the  labial  side  to  the  centre,  so  that  there  shall  be  no 
mistake  in  replacing  the  step-plug  in  its  proper  place  in  the 
impression. 

"  After  placing  the  plug  back  in  the  impression,  if  necessary, 
take  a  thin,  heated  spatula  and  stick  the  plug  fast  with  a  little 
hard  wax  on  the  outer  edge  so  that  it  may  not  be  disturbed 
in  pouring. 


Fig.  223. 


Fig.  224.       Fi<;.  225.       Fig.  226.  Fig.  227. 


Fig.  228. 


Fig.  229. 


"  Be  careful  not  to  get  any  wax  on  the  part  of  the  plug  where 
you  do  not  want  solder  to  flow  in.  Now  varnish  the  cast  as 
usual,  but  do  not  touch  the  plug  with  varnish.  Next  pour 
with  plaster  and  sand,  asbestos  or  pulverized  pumice-stone, 
any  one  of  which  will  do.  After  the  plaster  is  thoroughly 
hardened,  cut  it  away  in  the  usual  manner.  Place  the  articu- 
lation in  the  articulator  and  pour  in  the  usual  way.  The  tooth 
is  selected,  and  we  proceed  to  back  it  in  the  following  manner  : 
First  grind  and  fit  the  tooth  to  the  cast  and  cap  to  suit  you  ; 
then  cover  this  entire  inner  surface  with  thin  platinum,  the 
thinner  the  better.  Burnish  close  to  the  surface  of  the  tooth. 
Then  use  28-gauge  platinum  for  a  backing  down  to  where  the 


204  OPERATIVE    DENTISTRY. 

tooth  is  ground  out  to  fit  the  step-plug,  and  bend  the  pins 
down  to  hold  the  two  pieces  of  platinum  tight  to  the  tooth. 
We  now  have  Fig.  227,  representing  the  tooth  as  it  appears 
backed  ready  to  place  in  position. 

"  Next  place  the  tooth  in  position,  in  the  cast,  cover  with 
plaster  and  sand  and  solder  with  coin  gold.  After  finishing 
and  polishing  the  crown  is  ready  for  adjustment.  Moisten  the 
step-plug  and  cap  with  cement,  as  in  Fig.  228,  and  with  the 
little  roller,  seen  in  Fig.  229,  gently  press  the  crown  up  in 
position,  and  we  have  the  crown  completed  as  seen  in  Fig.  228. 

"  If  you  desire  a  cheap  crown,  solder  with  block  tin.  After 
experimenting  with  various  metals,  I  have  succeeded  in  mak- 
ing a  step-plug — or  tip,  as  I  usually  call  it — of  platinum  and 
nickel,  that  is  as  strong  as  steel,  and  cannot  be  melted. 

"  If  I  perfect  the  crown  myself,  I  take  a  shorter  way  :  After 
preparing  the  root  with  the  instrument,  and  placing  the  step- 
plug  in  position,  my  tooth  is  selected,  ground  and  arranged 
in  the  mouth,  after  which  I  back  the  tooth  as  before  de.scribed. 
I  warm  and  stick  to  the  backing  of  the  tooth  a  small  amount 
of  sticking-wax,  made  of  rosin,  gutta-percha  and  beeswax, 
and  place  the  tooth  in  position  in  the  mouth,  perfectly  imbed- 
ding the  top  of  the  step-plug  in  wax.  Great  care  must  be 
exercised  to  have  the  tooth  in  the  position  desired,  and  in 
pressing  the  tooth  and  wax  against  the  plug.  I  next  carefully 
remove  the  wax  and  tooth,  and  with  pliers  remove  the  step- 
plug  and  place  in  the  impression  just  made.  Then  with  a 
heated  spatula  I  stick  the  tip  and  wax  together,  pour  in  the 
usual  way,  and  in  a  few  moments  it  is  ready  to  solder.  Thus 
a  tooth  can  be  set  easily  in  one  hour's  time. 

"  To  crown  a  bicuspid  or  a  molar,  your  first  step  is  to  grind 
the  tooth-substance  even  with  the  margin  of  the  gum,  and 
then  use  your  drill.  In  drilling,  instead  of  following  the 
nerve-cavity  direct,  which  would  leave  the  instrument  a  little 
diagonal,  hold  the  instrument  perpendicular.  This  leads  the 
upper  portion  of  the  drill  to  the  outer  wall  of  the  root  and  brings 
the  lower  portion  of  the  drill  to  the  inner  side  of  the  root. 


LOW  S    CROWN.  205 

"  You  would  puncture  the  wall  of  the  root  if  you  went  deep 
enough,  but  there  is  no  need  of  going  to  such  a  depth.  Next 
take  No.  i  cutter,  which  will  invariably  be  the  instrument  to 
operate  on  all  the  bicuspid  and  molar  root-canals,  and  after 
carefully  cutting  to  the  depth  desired,  the  root  is  ready  for  the 
introduction  of  step-plug  of  same  size.  We  now  drill  one 
other  root  in  the  same  manner,  and  after  placing  the  step- 
plugs  in  position,  take  an  articulation  and  impression,  remove 
the  plugs  and  place  in  the  impression,  pour  and  separate  and 
place  in  the  articulator  as  before  described.  We  have  tvith 
the  adjoining  teeth  an  exact  impression  of  the  root  to  be 
crowned. 

"  Next  take  a  thin  piece  of  platinum  and  make  two  perfora- 
tions for  the  pins  on  the  end  of  the  step-plugs  to  enter,  press 
the  platinum  down  over  the  root  and  burnish  close  to  it ; 
then  remove  and  trim  by  the  marks  made  in  burnishing  to 
the  exact  shape  of  the  root. 

"  Place  the  platinum  on  the  root  again,  and  we  are  ready  to 
select  our  tooth.  This  should  be  made  the  same  as  is  used 
for  bridge-work,  with  gold  cusps,  so  no  breakage  can  possibly 
occur.  Place  the  tooth  in  position  in  the  articulator  and  hold 
in  place  with  wax.  Encase  in  plaster  and  sand,  and  fill  in  and 
solder  with  coin  gold,  or,  if  you  choose,  block  tin  can  be  used. 
After  polishing  and  burnishing,  you  have  a  strong,  durable 
crown,  ready  to  be  adjusted,  only  equalled  by  the  natural 
tooth. 

"  In  setting  a  bicuspid,  we  seldom  use  more  than  one  step- 
plug,  and  the  process  is  similar  to  setting  a  molar. 

"  Fig.  230  shows  the  root  cut  ready  to  receive  the  step-plug. 
Fig.  231  shows  us  the  step-plug  with  the  platinum  covering 
the  entire  tooth-surface.  In  Fig.  232  it  will  be  seen  that  the 
cap  to  the  step-plug  goes  below  the  surface  of  the  tooth, 
leaving  tooth-substance  all  the  way  round,  but  the  platinum 
that  is  soldered,  to  the  step-plug  rests  on  the  tooth-surface. 
In  Fig.  233  we  see  the  crown  ready  for  adjustment.  Fig.  234 
is  the  tooth  after  it  has  been  adjusted. 


2o6  OPERATIVE    DENTISTRY. 

"  These  plugs  can  be  used  to  great  advantage  in  varied 
dental  operations.  There  is  nothing  equal  to  them  for  restor- 
ing broken  and  decrepid  teeth  to  their  original  shape,  appear- 
ance and  usefulness.  I  use  them  exclusively  in  bridge-work. 
They  make  a  firmer,  stronger  and  more  durable  ground- 
work for  bridging  than  any  other  method  I  have  ever 
discovered. 

"  In  badly  decayed  molars,  where  there  is  not  sufficient  tooth- 
substance  to  hold  a  gold  crown  for  a  bridge,  I  always  stick 
one 'of  these  plugs  in  the  root  to  constitute  a  solid  foundation. 
If  the  pin  on  the  end  of  the  plug  for  removing  is  not  long 
enough,  it  can  be  very  readily  lengthened  by  soldering  a 
piece  to  it,  and  this  without  danger  of  injuring  or  melting. 
The    plugs    are    made   of  a   perfectly    non-corrosive    metal, 

Fig.  230.  Fig.  231.  Fig.  232.  Fig.  233.  Fig.  234. 


though  the  color  might  indicate  otherwise.  They  are  strong 
as  steel,  and  cannot  be  melted  by  any  heat  from  an  ordinary 
blowpipe."* 

The  Improved  Richmond  Crowns. — "  The  pivot  is  baked 
into  the  crown.  Prepare  the  root  and  adjust  the  tooth-crown 
to  place.  Fill  the  root  with  cement  and  insert  the  pin  of  the 
crown,  leaving  an  open  joint.  Pack  amalgam  between  the 
crown  and  root,  making  a  perfect  joint. 

"  Another.  Combine  with  the  band  and  cap  a  tube,  which  are 
secured  to  the  root  with  cement;  into  this  tube  the  pin  of  the 
porcelain  crown  is  cemented  with  gutta-percha  dissolved  in 
ether.     This  may  be  used  for  bridge-work.     The  supporting 

*"  Am.  Syst.  Dent.,"  IT,  905. 


MERIAM    CROWNS. 


loy 


roots  are  fitted  with  bands,  caj).s  and  tubes  the  same  as  for  a 
single  crown. 

"A  pin  is  attached  to  each  end  of  a  bridge-piece,  and  these 
pins  are  slipped  into  the  tubes  and  cemented  with  gutta-percha, 
or  ma\-  be  inserted  without  cement.  Such  cases  are  easil\- 
removed."* 

Meriam  Crowns. — Dr.  II.  C.  Meriam  constructs  an  all 
porcelain  crown  similar  to  the  English  tube  teeth  shown  in 
Figs.  235  and  236. 

Fir,.  235. 


Kir..  7-/. 


They  are  much  stronger  than  those  customaril)^  used.  He 
sets  them  in  a  band  which  is  fitted  to  the  root  and  crown,  and 
dowels  may  or  may  not  be  used  in  the  root.  Gutta-percha  or 
cement  may  be  used  to  set  them. 

"  The  band  is  fitted  to  the  root  and  the  crown  ground  into 
the  band  after  proper  occlusion  with  its  antagonist  has  been 
obtained.  If  a  molar,  a  fine  groove  is  ground  around  it,  and 
the  band,  after  being  corrugated  on  its  inner  surface  with  a 
small  bur,  is  placed  on  a  lead  anvil  and  the  tooth  driven  into 


*  Cosmos,  XXVI,  369. 


208 


OPERATIVE    DENTISTRY. 


it,  thus  partially  securing  the  advantage  of  union  by  gom- 
phosis.  The  common  glass  stopper  is  a  good  illustration  of 
how  little  more  than  its  fit  would  be  required  to  retain  it  firmly 
in  place.  For  this  little  I  have  drawn  on  the  tube-teeth  work- 
ers of  England.  A  few  small  pieces  of  sulphur  are  then  placed 
inside  the  band  and  all  held  over  a  small  flame  until  the 
sulphur  melts  and  flows  into  the  groove  between  the  band  and 
the  crown.  Zinc  phosphate  may  be  used  before  the  crown  is 
forced  in,  or  some  flux,  borax,  for  instance,  which  melts  at  a 
low  temperature,  though  this  would  probably  require  invest- 
ing. We  then  have  a  crown  which,  if  a  molar,  I  do  not  fear 
to  attach  with  gutta-percha  without  dowels  ;  but  others  may 
not  have   this  confidence,  and  dowels  may  either  be  put  into 


Fig.  237.  Fig.  238.  Fig.  239.  Fig.  240. 


the  roots  or  be  set  in  the  crown  with  cement,  and  afterward 
screwed  to  their  places  in  the  root  as  usual  (Fig.  237).  It  is 
evident  that  if  cement  is  strong  enough  to  hold  a  dowel,  it 
must  be  equally  serviceable  in  securing  the  crown  to  the  dowel. 
If  greater  security  is  desired,  a  fine  platinum  or  pure  gold  wire 
may  be  fitted  into  the  groove  around  the  crown  (Fig..  238). 
Drive  in  as  before ;  invest  and  solder  (Fig.  239).  For  the 
incisors  the  groove  should  not  run  around  the  anterior  face  of 
the  crown,  and  I  have  not  soldered  those  teeth  in  (Fig.  240). 
I  have  entire  confidence  in  any  form  for  the  incisors  and  bicus- 
pids where  the  root  is  well  banded,  the  dowel  put  into  the 
centre,  and  the  crown  forced  into  place  in  gutta-percha  (Fig. 
241);  while  for  the  molars,  if  quite  short  I  do  not  care  for  the 


MERIAM    CROWNS, 


209 


dowels.  You  will  notice  that  this  method  does  away  with 
much  of  the  showing  of  gold  in  molars  where  such  a  result  is 
desired  (Fig.  242). 

"  Another  form  for  molars,  although  it  shows  more  gold  than 
the  others,  is  perhaps  stronger.  The  band  is  made  full  width 
down  to  occlusion,  and  any  large,  strong  tooth  is  ground  to 
fit  the  space  in  the  arch.  This  is  driven  into  the  band  so  as 
to  be  even  with  its  edge,  and  cemented  with  sulphur  as  before 
(Fig.  243). 

"  Settini!^.  I  first  xarnish  the  band  inside  with  Canada  balsam 
dissolved  in  ether;  then  fill  the  crown  with  gutta-percha  and 
crowd  it  up  against  the  root  several  times  to  get  an  impression. 


Fic.  241. 


Fir..  242. 


Fig.  243. 


When  sure  that  I  have  the  right  amount  of  gutta-percha,  I 
place  the  dowels  in  the  root  (if  I  am  to  use  them),  heat  the 
crown,  dip  it  into  cajeput  or  any  essential  oil,  and  crowd  it  to 
place.  The  dowels  I  fit  in  the  same  way,  wrapping  them  with 
gutta-percha  and  working  up  and  down  in  the  root  until  I  get 
the  impression  before  the  final  forcing  to  place.  I  thus  have 
the  advantage  of  the  dowel  and  hard  centre  of  gutta-percha  to 
act  as  a  plunger,  and  the  soft  semi-dissolved  gutta-percha 
comes  back  on  the  outside  of  the  mass,  forming,  I  think,  the 
tightest  root-filling  known.  I  fill  roots  in  this  way  with  gutta- 
percha points  when  I  do  not  use  a  dowel.  The  dowels  used 
are  made  by  wrapping  a  piece  of  platinum  and  iridium  wire 
with  about  one-third  of  a  sheet  of  gold-foil,  which  is  melted 


2IO 


OPERATIVE    DENTISTRY. 


on,  and  the  combination  made  true  by  being  drawn  once 
through  a  wire-gauge.  A  piece  of  piano-wire  is  then  wound 
around  it  three  or  four  times  to  serve  as  a  guide,  and  a  fine 
platinum  wire,  previously  drawn  square,  is  caught  and  turned 
through  the  wire-guide  a  few  times,  when  the  winding  may 
either  be  finished  by  hand  or  the  end,  after  being  started,  may 
be  placed  in  a  lathe-chuck  and  wound  up  at  once  (Fig.  244). 
A  piece  of  gold  foil  is  then  wrapped  around  the  whole  and  the 
fine  wire  soldered  on.  A  dowel  made  in  this  manner  is  not 
strained  by  having  its  thread  cut,  and  the  thread  being  square 

Fig.  244. 


and  coarse  or  fine,  as  you  wish,  is  strong  and  possesses  plenty 
of  grip. 

"  When  a  root  has  broken  off  far  under  the  gum,  it  should  be 
filled  with  gutta-percha  and  a  temporary  plate  worn — if  the 
loss  be  in  the  front  of  the  mouth — until  it  works  down,  when 
it  may  be  crowned  and  the  plate  given  up. 

"  In  preparing  roots  after  a  large  portion  of  the  crown  is 
broken  away,  I  enlarge  the  pulp  chamber  with  a  large,  round 
bur,  and,  when  even  with  the  ffum,  follow  with  the  revolving 
saw  here  shown  (Fig.  245).     With  this  saw  I  often  cut  off  the 


THE    MATTISON    CROWN. 


21  I 


remnants  of  a  crown  from  the  inside  without  woundin<;  the 
gum  or  drawing  a  drop  of  blood,  and  am  saved  the  unpleasant- 
ness of  running  a  stump  corundum  wheel  in  the  mouth. 


Fir..  245. 


Fig.  246. 


"  The  outside  of  the  root  can  sometimes  be  formed  with  the 
instruments  here  shown  "*  (Fig.  246). 

The  Mattison  Crown. — "The  root  upon  which  the  crown 
is  to  be  mounted  should  be  placed  in  a  healthy  condition, 
with  the  pulp-canal  filled  at  the  apex,  the  end  ground  off 
below  the  free  margin  of  the  gum  in  front  and  within  an 
eighth  of  an  inch  of  the  gum  on  the  inner  or  lingual  surface, 
the  end  of  the  root  countersunk,  and  the  pulp-canal  enlarged 
sufficiently  to  receive  a  platinum  wire — No.  18  or  20,  standard 
plate  gauge — with  a  screw-thread  cut  thereon.  This  should  fit 
tightly  enough  to  take  firm  hold.  Further,  enlarge  one-half 
the  length  of  the  pulp-canal  with  a  cone-shaped  bur  with  its 
base  toward  the  apex,  as  represented  in  No.  i  (Fig.  247). 
Previous  to  grinding  the  end  of  the  root  below  the  gum  in 
front,  with  fine  binding  wire  take  a  measurement  of  the  cir- 
cumference of  the  root  at  the  marsfin  of  the  crum.     Cut  across 


*  See  Cosmos,  xxvni,  493. 


212 


OPERATIVE    DENTISTRY, 


at  intersection,  and  carefully  remove  the  wire  ring  thus  formed, 
without  changing  its  shape.  Take  an  impression  of  its  form, 
by  placing  it  between  a  sheet  of  writing  paper  and  a  smooth 
surface,  and  by  rubbing  the  end  of  a  finger  thereon  the  out- 
line will  appear.  This  is  the  outline  of  the  end  of  the  root ; 
from  this  cut  a  pattern.     Dissect  the  gum  from  the  end  of  the 

Fig.  247. 


root  up  to  the  alveolar  process.  Select  a  die  (forms  shown  in 
Fig.  247)  similar  in  shape  to  the  root  you  wish  to  reproduce. 
Make  a  pattern  of  the  shell  by  pressing  between  the  dies  a 
piece  of  pattern  tin,  leaving  an  opening  in  front  as  represented 
in  No.  3  (Fig.  247),  the  cut  being  on  a  line  with  the  edge 
on  one  side.  Remove  this  pattern  and  press  into  as  plain  a 
surface  as  possible  without  .stretching  the  margins. 


THE    MATTISON    CROWN.  21  3 

"Cut  the  ^old-and-platinum  plate  to  pattern,  making  it  wider 
or  narrower  as  the  wire  measurement  of  the  end  of  the  root 
compared  with  the  pattern  indicates.  Anneal  and  place  the 
plate  in  the  same  position  between  the  dies  as  that  previously 
occupied  by  the  pattern,  and  press  into  form  ;  remove,  bring 
the  edges  together  without  lapping  and  solder  with  pure  gold. 
The  shell  may  be  made  longer  or  shorter,  wider  or  narrower, 
than  the  die  upon  which  it  was  made,  as  the  case  demands. 

1^'it  the  shell  to  the  root ;  trim  the  root  end  of  the  shell 
until  it  occupies  its  proper  position  and  the  articulation  is 
correct,  which  is  determined  by  the  patient  closing  the  teeth. 
The  corners  at  the  cutting  edge  and  sides  should  be  cut  and 
the  edges  brought  together  without  lapping,  and  also  soldered 
with  pure  gold. 

Then  from  platinum  plate.  No.  28,  cut  the  ring,  No.  4 
(Fig.  247),  to  the  proper  pattern.  This  forms  the  shoulder 
within  the  shell  (the  opening  in  the  ring  may  be  cut  out  with 
a  plate  punch).  Place  the  shell  in  position  on  the  root,  the 
teeth  closed ;  insert  the  ring,  which  should  rest  upon  the  end 
of  the  root  midway  the  width  of  the  band  in  front,  and  should 
fit  the  shell  so  tight  that  both  can  be  removed  without  chang- 
ing their  relative  positions.  Remove  from  the  root,  and  with 
a  fine  camel's-hair  a'pply  borax  finely  ground  in  water.  At  the 
junction  of  the  two  pieces  place  a  small  piece  of  twenty-carat 
solder  on  the  inner  surface,  /.  e.,  toward  the  cutting  edge  of 
the  shell,  to  prevent  an  excess  of  solder  flowing  between  the 
shoulder  on  the  end  of  the  root  upon  which  it  will  rest.  Flow 
the  solder,  which  should  merely  tack  the  ring  in  place  at  the 
front.  Try  upon  the  root  to  make  sure  of  its  being  correct ; 
remove  and  complete  the  soldering. 

"The  shell  may  be  strengthened  by  flowing  inside  a  lower 
grade  of  solder  than  previously  used  at  such  places  as  desired. 

"Select  a  plain  rubber  tooth  and  fit  it  to  the  opening  in  the 
shell  (which  may  be  removed  for  the  purpose),  and  with  a 
corundum  wheel  and  disk  grind  a  dovetailed  slot  in  the  back 
(see  No.  5,  Fig.   247),  running    lengthwise,  and   sufficiently 


214  OPERATIVE    DENTISTRY. 

deep  to  permit  the  platinum  screw  to  extend  two-thirds  the 
length  of  the  crown  without  interference. 

"  To  Anchor  the  Croivn  to  the  Root. — Place  the  shell  in  posi- 
tion ;  apply  the  rubber  dam  over  it  and  the  adjoining  teeth, 
turning  the  edges  well  under  the  gum;  remove  the  shell;  the 
dam  will  remain  in  position. 

"  Dry  the  pulp-canal,  insert  the  wire  screw,  cut  it  off  the 
required  length,  and  with  amalgam  mixed  hard  fill  around  the 
screw  in  the  root,  and  covering  the  end,  again  replace  the 
shell  on  the  root  (the  end  of  the  screw  should  be  bent  against 
the  inner  wall  of  the  shell  when  the  teeth  are  closed,  so  as  to 
fall  into  the  dovetailed  slot  in  the  porcelain  front  when  that  is 
inserted).  Continue  the  amalgam  filling  through  the  opening 
in  the  front  of  the  shell,  around  the  screw  and  over  the 
shoulder,  as  represented  in  No.  i  (Fig.  247) ;  and  with  oxy- 
phosphate  cement  complete  by  filling  around  the  wire  and  in 
the  slot  of  the  front,  which  is  then  inserted  and  pressed  into 
position  between  the  thumb  and  finger-,  the  excess  escaping 
at  the  edges. 

"  Burnish  the  edges  of  the  shell  around  the  neck  of  the  root 
and  porcelain  front.  Instruct  the  patient  not  to  disturb  for 
from  four  to  six  hours."  * 

Dr.  Kirk's  Crown. — "The  root  is  prepared  in  the  usual 
manner  by  carefully  closing  the  apical  foramen  with  gold  or 
gutta-percha,  and  removing  all  softened  dentine  from  the 
canal,  which  is  then  undercut  or  roughened  with  -a  wheel- 
bur.  The  apical  end  of  the  pulp-canal  is  enlarged  by  a  drill, 
and  a  thread  cut  in  the  dentine  by  means  of  one  of  How's 
drill  taps.  Only  a  small  portion  of  the  upper  end  of  the 
canal  is  so  tapped,  just  sufficient  to  engage  from  a  sixteenth 
to  an  eighth  of  an  inch  of  the  end  of  the  screw-post,  as 
dependence  is  placed  mainly  upon  the  cement  lining  for 
anchorage.  A  collar  of  22-carat  gold.  No.  30,  having  its 
edges  smoothly  bevelled,  is  accurately  fitted  to  the  end  of  the 

*  "  Am.  Syst.  Dent.,"  11,  932. 


DK 


KIRK  S    CROWN, 


215 


root  and  driven  ti^^htly  on  to  it,  until  it  extends  somewhat 
over  one  thirty-second  of  an  inch  under  the  J^um.  The  collar 
is  cut  short  upon  the  labial  side  and  left  lon^  upon  the  lin<;u;il 
side,  so  that  it  extends  nearly  to  the  grinding  surface  of  the 
lingal  cusp  of  the  finished  crown,  but  is  visible  only  as  a  nar- 
row band  upon  the  buccal  surface  at  the  gingival  margin. 

"  When  the  band  has  been  satisfactorily  adapted  in  the 
manner  described,  a  Foster  crown,  which  has  been  previously 
adapted  to  the  end  of  the  root  by  careful  grinding,  is  adjusted 
inside  the  root-collar.  The  crown  selected  should  have  a 
greater  circumference  than  the  end  of  the  root,  so  that  by 
grinding  it  down  somewhat  conically  on  its  lingual  and  proxi- 
mal surfaces,  it  can  be  tightly  adjusted  to  the  collar. 


"  If  a  crown  smaller  than  the  collar  is  taken  a  tight  joint 
cannot  be  made.  When  the  crown  has  been  carefully  fitted 
to  its  place,  a  tight  joint  secured,  and  the  proper  occlusion 
obtained,  a  gold  screw  with  a  head  upon  it,  similar  to  the  ordi- 
nary gimlet-pointed  wood  screw,  is  passed  through  the  central 
opening  in  the  crown,  carried  up  until  it  engages  in  the  den- 
tine at  the  apical  end  of  the  root,  and  driven  home  with  a 
small  screw-driver,  and  its  proper  length  adjusted  so  that  it 
firmly  holds  the  crown  and  band  in  their  proper  relations  to 
the  root,  as  seen  in  Fig.  248. 

"  When  all  has  been  satisfactorily  adjusted,  the  screw  and 
crown  are  removed,  and  the  root-canal,  band  and  surrounding 
parts   thoroughly    dried ;  the    crown   is    to    be    permanently 


2l6  OPERATIVE    DENTISTRY. 

attached  by  filling  the  root  full  of  slow-setting  oxyphosphate 
of  zinc  mixed  rather  thin  ;  the  crown  is  then  pressed  firmly 
into  its  place,  when  the  excess  of  cement  will  flow  through 
the  central  opening  in  the  crown  ;  the  gold  screw  is  then  to 
be  pressed  through  the  crown  and  driven  quickly  to  its  seat 
by  the  screw-driver,  all  excess  of  cement  passing  out  as  before 
through  the  central  opening  of  the  crown  and  alongside  the 
screw. 

"  After  the  cement  has  hardened,  all  excess  is  cut  from 
around  the  screw  head  by  means  of  an  excavator,  after  which 
the  screw-head  is  covered  and  the  countersunk  opening  in  the 
crown  filled  with  gold,  anchorage  for  the  fitting  being  obtained 
by  cutting  a  groove  around  the  base  of  the  screw-head  by 
means  of  a  small  wheel-bur.  The  completed  operation  is 
shown  in  Fig.  249."* 

The  Leech  Crown. — "Prepare  the  root  with  a  stump 
corundum  wheel,  and  drill  it  out  three-eighths  of  an  inch  in 
depth,  of  a  diameter  of  about  No.  16  standard  wire-gauge, 
enlarging  it  at  the  bottom,  as  shown  in  Fig.  250.  Now  fill 
the  canal  in  the  root  with  gutta-percha  or  oxychloride  of  zinc. 

Fig.  250.  Fig.  251.  Fig.  252. 

Hi 


make  a  gold  tube  to  fit  nicely  the  aperture  in  the  root,  about 
three-quarters  of  an  inch  in  length,  so  that  it  can  be  more 
easily  handled  subsequently  ;  adapt  a  plate  of  gold  or  platinum 
to  the  face  of  the  root ;  cut  a  hole  in  it  to  correspond  to  the 

*  "  Am.  Syst.  Dent.,"  11,  774. 


THE    STOWELL    CROWN.  2  1/ 

size  of  the  tube  ;  insert  the  tube ;  set  the  plate  over  it ;  adjust 
it  to  the  face  of  the  root ;  hold  it  in  position  by  any  suitable 
cement ;  remove  the  tube  and  plate  and  unite  them  by  solder  ; 
insert  again  in  the  root,  and  adapt  a  plain  plate  tooth,  w  ith  a 
j^old  backin^f,  holdinLj  it  in  position  with  a  little  wax  or  cement. 
Now  remove  the  tube,  plate  and  tooth  to<^ether  and  solder  the 
tooth  in  place,  as  shown  in  Vlij;.  25  i.  Then,  with  a  small  sepa- 
rating file  or  saw  slit  the  tube  in  two  or  more  places  for 
about  two-thirds  of  its  length  ;  finish  up  the  back  of  the  tooth, 
cutting  away  the  superfluous  tubing.  Now  place  a  thin  sheet 
of  gutta-percha  on  the  upper  surface  of  the  plate — that  which 
is  adapted  to  the  face  of  the  root ;  warm  the  tooth  and  plate 
over  a  spirit  lamp,  and  press  it  up  against  the  root.  The 
gutta-percha  will  thus  hold  the  artificial  crown  temporarily  in 
position,  and,  covering  the  whole  face  of  the  root,  make  a  per- 
fect joint,  shown  as  completed  in  Fig.  252.  With  a  straight 
plugger  fill  the  tube  with  gold  or  tin  foil,  condensing  it  so  as 
to  spread  the  split  tube  to  correspond  with  the  cavity  in  the 
root.  The  tooth  is  thus  dovetailed  into  the  cavity,  so  that  it 
is  almost  impossible  that  it  should  become  loosened,  the  filling 
of  the  tube  making  it  almost  equal  to  a  solid  gold  wire. 

"  The  advantage  of  this  method  consists  in  the  certainty 
which  attends  each  stage  of  the  operation,  no  guess  work 
about  it,  no  screws  to  become  loose.  The  tube  so  fills  the 
entire  cavity  of  the  root  that  there  is  no  waste  motion,  allow- 
ing it  to  work  loose."* 

The  Stowell  Crown. — I  countersink  the  end  (Fig.  253), 
using  for  that  purpose  a  large,  round  bur  in  the  engine.  I 
now  make  a  closed  cap,  using  the  combination  crown  metal, 
and  place  it  upon  the  root.  The  cap  is  then  perforated  and 
the  root  reamed  for  the  dowels.  The  bite  in  wax  is  now 
taken,  after  which  the  cap  is  burnished  into  the  countersunk 
end  of  the  root  (Fig.  254).  The  dowels  of  platinum  and 
iridium  wire  are  now  set  in  their  places,  being  allowed  to  pro- 

*  Cosmos,  XXI,  232, 
IS 


2l8 


OPERATIVE    DENTISTRY. 


ject  one-fourth  of  an  inch,  so  that  they  may  adhere  to  the 
impression  of  plaster,  which  is  then  taken.  From  this  a  cast 
is  made,  of  investing  material — calcined  marble-dust  and  plaster 
is  preferable,  though  fine  moulding  sand  will  do.  The  dowels 
are  now  cut  off  even  with  the  top  of  the  cap  (Fig.  255). 

The  tooth  to  be  used  may  be  a  Logan  or  an  E.  Family 
Brown  crown,  or  a  common  countersunk  tooth,  but  I  would 
in  most  cases  recommend  the  Logan  crown.  As  the  case  in 
question  is  a  bicuspid,  I  have  selected  for  it  a  J^ogan  crown. 
First,  I  cut  off  the  pin,  and  then  the  tooth  is  ground  into  posi- 
tion on  the  cap,  grinding  the  stump  of  the  pin  and  porcelain 
alike  evenly  and  smoothly.  The  stump  of  the  pin  is  now 
ground,  with  a  small  wheel,  below  the  surface  of  the  porcelain 

Fig.  253.    Fig  254.  Fig.  255.  Fig  256    Fig  257.    Fig.  258.   Fig  239   Fig  260. 


(Fig.  256).  The  tooth  is  now  invested  (Fig.  257),  and  pure 
gold  fused  on  to  the  platinum  pin,  and  while  in  a  fluid  state  it 
is  with  a  wax  spatula  spatted  down  flat  (Fig.  258).  The  gold 
is  now  filed  or  ground  down  even  with  the  porcelain,  and  at 
the  palatal  border  the  tooth  is  ground  to  bevel  back  until  the 
gold  is  reached  (Fig.  259).  The  tooth  is  now  fastened  in 
place  on  the  cap -with  wax  cement  (Fig.  260),  the  cast  cut 
away,  and  the  case  invested  in  asbestos  and  plaster  (Fig.  261). 
This  is  used  because  of  the  fibre  of  the  asbestos,  which  pre- 
vents the  separation  of  the  crown  and  cap.  The  case  is  now 
heated  until  the  wax  has  melted  and  burned  out ;  a  small  clip- 
ping of  thin  platinum  plate  is  crowded  into  the  opening  (Fig. 
261)  caused  by  the  grinding  of  the  bevel  on  the  crown.  The 
clipping  of  platinum  serves   as  a  lead  for  the   solder,  which 


THE    STOWKLL    CROWN. 


219 


follows  it  down  into  the  countersunk  cap,  around  the  ends  of 
the  dowels,  and  finally  attaches  itself  to  the  pure  <^old  alread\- 
firmly  attached  to  the  stump  of  the  platinum  pin.  When  cool 
the  case  is  removed  from  the  investment,  dressed  and  polished, 
and  the  work  is  done  (Fig.  262).  A  sectional  view  of  a  like 
tooth  (Fig.  263)  shows  the  organization  in  detail. 

I'^ig.  264  shows  a  central  incisor  root  on  which  a  Logan 
crown  is  used  after  nn-  method,  h'ig.  265  shows  how  delicate 
an  operation  of  this  kind  may  be  performed  upon  an  inferior 
central  incisor,  b\'  the  use  of  the  countersunk  tooth  crown, 
which  is  shown  as  it  appears  before  gold  has  been  melted  in 
its  cup  around  the  pin,  a,  when  the  cup  has  been  filled  with 
gold,  H,  and  after  the  crown  has  been  ground  and  beveled,  c. 


Fig.  261.  Fig.  262.  Fig.  263.       Fig.  264. 


Fig.  263. 


Fig.  266. 


A  countersunk  molar  crown  is  shown  as  likewise  mounted  on 
the  roots  of  a  superior  left  second  molar  (Fig.  266). 

The  cuts  are  made  from  photographs  of  prepared  specimens, 
the  natural  roots  of  which  \-ary  in  the  several  figures,  and  in 
the  section  (Fig.  263)  the  continuation  of  the  pulp  canal  does 
not  appear,  because  obliterated  in  preparing  the  section. 

The  claims  for  this  method  of  crown  work  are  as  follows  : 
The  combination  of  an  all-porcelain  crown  with  a  closed  cap 
and  dowels,  the  adajitation  of  which  crown  and  its  final  attach- 
ment to  the  root  can  be  made  perfect. 

The  dowels  may  be  set  at  any  angle  that  the  direction  of 
the  root  canal  may  indicate,  using  one  or  more  dowels  as  the 
case  may  require,  and  when  the  root  has  to  be  cut  off  much 


220  OPERATIVE    DENTISTRY. 

below  the  gum,  and  a  collar  cannot  be  placed,  a  platinum 
disk  floor  on  the  root  end  is  the  preferable  plan.  The  well- 
known  and  easily  detected  plate-tooth  having  a  gold  backing 
which  renders  the  tooth  dull  in  appearance  is  thus  made  obso- 
lete, for  this  crown  possesses  the  translucent  appearance  of  the 
natural  organ.  Best  of  all,  the  glaring  gold  of  which  some 
so-called  beautiful  crowns  are  almost  entirely  composed  is  by 
this  means  superseded.  I  hereby  refer  to  gold  bicuspids  and 
molars,  more  especially  to  the  former,  which  have  always  been 
an  eyesore  to  me,  and  it  was  the  unsightly  appearance  of  these 
which  first  led  me  to  try  and  improve  on  them. 

*  Cosmos,  XXIX,  642. 


BRIDGE    WORK.  221 


BRIDGE  WORK 


Bridge  work  seems  to  have  passed  the  stage  of  experiment 
and  to  liave  been  established  as  one  of  the  useful  and  desira- 
ble operations  in  dentistry.  It  consists  of  false  crowns  sup- 
ported in  the  place  of  extracted  teeth,  independent  of  the 
gums,  by  roots  adjoining  the  space  to  be  filled.  The  supports, 
properly  called  abutments,  may  be  on  the  back  teeth,  cap 
crowns,  or  a  bar  fitted  into  a  cavity  of  the  tooth  and  secured 
by  filling ;  if  a  front  tooth,  a  Richmond  collar  crown,  t)r 
an  open  cap,  as  in  Fig.  267,  made  by  cutting  out  the  front 

Fir..  267. 


of  a  cap,  leaving  only  a  narrow  band  at  the  neck.  This, 
if  skillfully  adjusted  and  finished,  closely  resembles  a  gold 
filling.  Such  caps  may  be  applied  with  success  to  bicus- 
pid and  cuspid  teeth.  They  are  oftenest  required  on  the 
cuspids. 

The  cuspid  crown  should  be  dressed  down  until  of  uniform 
size  with  the  neck  of  the  tooth.  Fit  a  band,  as  wide  as  the 
length  of  the  crown,  of  20-carat  No.  31  gold,  closely  to  the 
neck  of  the  tooth,  and  solder.  The  palatine  portion  will  stand 
away  from  the  tooth  ;  into  this  space  place  a  piece  of  No. 31 
pure  gold  and  fit  it  to  the  palatine  surface  of  the  tooth,  secure 
it  with  wax  cement,  then  invest  and  solder  to  the  band. 
Grind  off  the  surplus  from  the  palatine  surface,  and  cut  out  the 
labial  surface  as  directed,  when  it  will  be  found  to  fit  very  per- 
fectly if  carefully  done. 

The  band  may  be  made  of  pure  gold,  thin,  and  fitted  with 


222  OPERATIVE    DENTISTRY. 

• 

the  pliers  and  burnishers  to  the  crown,  carefully  removed  and 
filled  with  strong  investment,  and  then  covered  with  a  second 
layer  of  gold  of  coarser  grade,  and  soldered.  Very  thin 
platinum  may  be  thus  used,  and  a  very  perfect  fit  obtained. 
Some  obtain  an  impression  of  the  crown  by  use  of  the  thin  plati- 
num, and  from  this  make  a  metal  die  and  strike  up  a  cap  upon 
it.     Skilled  operators  obtain  very  accurate  fits  in  this  way. 

Bicuspid  teeth  may  be  neatly  fitted  with  an  open  cap, 
and  have  the  lingual  cusp  covered  with  pure  gold.  When 
the  cap  is  finally  adjusted  with  the  cement,  the  edge  of  pure 
gold  may  be  burnished  down  to  the  surface  of  the  tooth,  and 
it  will  remain  in  perfect  adjustment.  The  cusp  and  that  of  the 
opposing  tooth  may  be  ground  a  little  to  compensate  for  the 
thickness  of  the  gold. 

In  the  cases  above  described  the  bands  are  expected  to  be 
accurately  fitted  to  the  festoon  of  the  gums,  and  to  pass  a 
little  way  under,  so  the  gum  will  completely  cover  the  edge. 

Sometimes  it  is  more  desirable  to  cap  the  teeth  without 
dressing  down,  and  also  not  to  have  the  cap  reach  the  gum, 
leaving  the  neck  of  the  tooth  fully  exposed. 

Many  patients  will  avail  themselves  of  the  benefits  of 
bridge  work,  if  they  do  not  have  their  teeth  ground  away,  who 
would  not  otherwise  do  so. 

For  such  a  case,  make  a  band  of  pure  gold,  reaching  nearly 

down  to  the  gum,  cover  the  grinding  surface,  as    in  other 

cases,  and  a  band  of  thin  22-carat  gold  outside  the  pure  gold 

band,  but  narrower,  leaving  a  free  edge  of  pure  gold,  which 

may  be  burnished  down   around   the   crown 

when  it  is  finally  adjusted  with  the  cement. 

C^fm .5      Fig.  268  shows  such  a  cap,  a  being  the  pure 

|jnp|gy[ a      gold  and,  b  the  thickened  portion  of  the  cap. 

The  bar  anchorage  is  made  as  follows  :  "  A 
slot  for  the  bar  must  be  cut  in  the  grinding  surface  of  the 
crown.  In  a  large  percentage  of  cases  a  crown  cavity  will  be 
found  in  molars  ;  this  affords  a  convenient  point  for  starting 
the   slot.     Frequently,  but  little   more  is  necessary  than  the 


HRinOE    WORK.  223 

enlarf^cmcnt  or  elon<:jatic)n  of  the  cavity  in  the  mesial  direc- 
tion. Wlien  it  is  necessary  to  start  the  excavation  dc  novo,  it 
is  best  accomplished  by  means  of  a  small  corundum  disk, 
which  will  rapidly  make  an  elongated  cut  through  the  enamel, 
thus  rendering  the  subsequent  cutting  comparatively  easy. 
The  slot  need  not  necessarily  be  more  than  one-eighth  inch 
long,  although  one-fifth  inch  is  a  better  length  ;  its  depth  will 
depend  upon  the  position  of  the  pulp  chamber,  the  sensitive- 
ness of  the  tooth,  the  strength  of  its  walls,  and  the  nature  of 
the  occlusion.  Its  width  should  not  exceed  one-tenth  of  an 
inch,  and  may  be  less.  The  lower  second  molar  tooth  is  fre- 
quently so  much  tilted  in  a  forward  direction  that  there  is 
quite  a  considerable  space  between  it  and  the  mesial  portion 
of  the  grinding  surface  of  the  antagonizing  upper  molar.  In 
such  cases  quite  a  thick  bar  can  be  placed  in  position  and 
allowed  to  rise  above  the  general  level  of  the  tooth  upon 
which  it  rests,  the  slot  being  made  only  deep  enough  to  secure 
its  proper  anchorage.  Where  the  bite  is  very  close  at  all 
points,  the  slot  and  bar  must  be  sunk  deeper.  The  slot  should  . 
be  dovetailed  and  undercut,  as  seen  in  Fig.  269.  The  anchor- 
age-bar   should    be    made    of  platinum 

alloyed  with  iridium,  and  should  corres-  "^"  ^^"  'c-^yo- 

pond  in  shape  to  the  slot,  but  be  made 
as  much  smaller  as  may  be  necessary  to 
afford  space  for  packing  around  it,  with 
very  fine  instruments,  either  foil,  amal- 
gam, or  cements  for  anchorage  purposes.  I"ig.  270  shows  a 
desirable  shape  for  the  anchorage-bar  in  the  case  under  stud\'. 
The  notch  on  its  surface,  filled  in  with  a  strong  packing,  will 
fully  counteract  any  tendency  to  movement  in  a  forward 
direction  which  might  otherwise  be  manifested  in  wear."* 

Another  manner  of  connecting  false  crowns,  when  a  natural 
tooth  intervenes,  is  by  co/niccting  bands.  They  are  made  as 
follows : — 

*  "  Am.  Syst.  Dent.,*'  Vol.  u,  p.  846. 


224  OPERATIVE    DENTISTRY. 

Fig.  271  illustrates  this  device  for  obviating  the  neces- 
sity for  removing  the  crowns  of  natural  teeth  in  prepar- 
ing the  mouth  for  bridge  work.  Crowns  are  fitted  in  the 
mouth  to  the  points  of  attachment  in  the  usual  manner.  An 
impression  is  taken,  bringing  the  crowns  away  in  their  proper 
positions.  From  this  the  cast  or  model  is  obtained.  Heavy 
bands  of  half-round  gold  or  platinum  bars  are  now  fitted 
around  the  necks  of  the  natural  teeth,  on  their  lingual  sur- 
faces. These  bands  being  waxed  in  position,  serve  to  connect 
the  different  parts  of  the  bridge,  uniting  them  in  one  piece 
without  the  loss  of  any  of  the  natural  crowns.  I  have  found 
this  a  highly  satisfactory  method  of  inserting  extensive  pieces 

Fig.  271. 


of  the  work.  Fig.  272  shows  the  mouth  as  presented,  for 
which  the  piece  shown  in  Fig.  271  was  constructed.  Fig.  273 
shows  the  piece  in  position."  * 

The  false  crowns,  more  frequently  called  dummies,  are  so 
made  as  to  present  only  an  edge  toward  the  gum  while  having 
a  full  grinding  surface  presenting  to  the  opposing  tooth. 

The  common  way  of  making  them  is  to  select  a  suitable 
porcelain  face,  grind  the  neck  thin  so  that  only  an  edge  will 
come  in  contact  with  the  gum,  and  grind  the  cutting  edge 
square,  a  little  shorter  than  the  occlusion  requires.     Take  a 

*  Cosmos,  xxvn,  712, 


BRIDGE    WORK. 


225 


piece  of  pure  gold,  struck  to  the  form  of  the  grinding  surface 
of  a  corresponding  tooth  by  a  die  previously  prepared,  or 
formed  to  the  occluding  surface  of  the  opposing  tooth,  melt 


Fig.  272. 


coin  gold  into  the  concave  surface  of  this,  file  or  grind  this 
surface  smooth,  and  fit  it  to  the  porcelain  face  already  pre- 
pared and  backed  with  pure  gold. 


Fi< 


When  fitted  and  secured  in  position  with  wax  cement,  place 
upon  each  side  of  the  crown  a  triangular  piece  of  pure  gold 
or  platinum  closely  adjusted  to  the  sides  of  the  porcelain,  and 


226  OPERATIVE    DENTISTRY. 

secure  them  in  position.  Invest  this,  wash  out  the  wax,  and 
this  will  expose  a  triangular  box  into  which  should  be  flowed 
coin  gold  or  No.  i  solder.  Fig.  274  shows  different  views  of 
these  crowns  completed. 

An  excellent  molar  or  bicuspid  crown  for  bridge  work  may 
be  made  by  using  a  common  rubber  tooth,  grinding  off  the 
shoulder  a  little,  and  cutting  off  the  heads  of  the  pins  and 
wrapping  it  with  pure  gold  No.  30  or  31,  as  in  Fig.  275.  To 
do  this,  take  some  thick  pattern  tin  and  punch  holes  for  the 
pins  and  fold  it  around  the  tooth,  overlapping  a  little  at  some 
point.  Cut  out  the  grinding  and  buccal  surface  of  the  crown, 
leaving  a  band  at  the  cervical  portion,  remove  the  tin  and 
spread  it  out.  It  will  be  a  correct  pattern,  by  which  to  cut 
the  pure  gold,  which  will  be  found  to  fit  correctly,  when  the 


Fig.  274. 


tooth  may  be  invested  and  soldered  with  18  k.  plate.  Be  sure 
the  gold  is  burnished  down  to  contact  with  all  parts  of  the 
tooth.  Special  care  should  be  taken  in  heating  and  cooling 
when  soldering  these  crowns,  to  avoid  fracture  of  the  porce- 
lain. 

If  great  strength  is  required,  the  neck  of  the  tooth  may  be 
shortened  and  additional  thickness  of  gold  added.  Crowns 
thus  prepared  and  placed  in  position,  and  a  bar  of  gold  added 
to  the  lingual  surface  to  strengthen  them,  and  all  well  soldered, 
make  work  of  superior  excellence.  It  avoids  the  unsightly 
and  glaring  gold  crown,  and  affords  a  porcelain  biting  surface, 
which  is  very  much  more  agreeable  and  serviceable  to  bite 
upon.  The  English  tubs  teeth  can  generally  be  used  for  the 
.same  object,  by  first  making  the  bridge  frame  and  soldering  a 


BRinOE    WORK.  227 

pin  in  position  and  slippin<^  on  one  of  these  teeth  ground  to  a 
proper  length,  and  secured  by  gutta-percha  or  cement. 

When  all  parts  are  made  to  fit  their  places,  one  or  two  false 
crowns  may  be  attached  by  wa.x  cement  to  the  adjoining 
abutment,  placed  in  the  mouth  and  accurately  adjusted  to 
position  and  occlusion,  and  then  removed,  invested  and  sol- 
dered. This  may  be  done  on  each  enil,  so  the  bridge  will  con- 
sist of  only  two  parts.  When  this  is  done,  place  the  two  parts 
in  position,  have  the  patient  close  the  teeth  and  hold  the  parts 
to  a  correct  occlusion.  Mix  some  investment  to  set  quickly, 
draw  away  the  lips  and  cheek  and  cover  the  outer  surface  of 
the  bridge  with  the  investment.  When  firmly  set,  remove  it. 
This  will  be  a  matrix,  into  which  the  pieces  of  the  bridge  may 
be  placed  in  correct  relation  to  each  other.  Secure  by  a  little 
wax  at  a  few  points,  to  insure  against  moving.  Place  around 
this  more  investment,  then  gold  plate  may  be  added  as  is 
needed  to  strengthen  the  bridge,  and  the  case  soldered  and 
finished,  and  adjusted. 

The  method  of  making  the  artificial  crowns  for  the  bridge 
is  given  in  the  following  description  of  a  case  taken  from  Dr. 
Litch's  excellent  article  in  the  "American  System  of  Den- 
tistry." 

"  The  anchorage  being  now  fully  prepared,  the  cuspid  and 
molar  caps  are  placed  in  position,  and  with  plaster  an  impres- 
sion of  the  mouth  is  taken.  If  the  caps  do  not  come  away 
with  the  impression,  they  are  withdrawn  from  the  mouth  and 
placed  in  their  proper  position  in  the  impression,  which  is  then 
varnished  or  oiled,  or  both,  and  a  cast  run  after  the  usual 
manner.  After  removal  of  the  impression  the  caps  will  be 
found  implanted  in  their  proper  positions  upon  the  cast,  as 
seen  in  Fig.  276.  To  facilitate  the  subsequent  removal  of  the 
cuspid  caps,  the  inner  and  the  outer  surfaces  of  the  ferrule 
portions  and  the  sides  of  the  retaining-pins  should  be  coated 
with  a  thin  film  of  paraffine  and  wa.x,  which  by  the  applica- 
tion of  a  little  heat  will  readily  soften  and  permit  the  with- 
drawal from  the  cast.     After  the  wax  film  has  been  removed, 


228 


OPERATIVE    DENTISTRY. 


the  caps  can  be  replaced  in  and  withdrawn  from  their  places 
on  the  cast  at  pleasure.  A  similar  method  should  be  adopted 
with  the  molar  caps.  Enough  wax  should  be  placed  upon  its 
inner  surface  to  fill  out  the  curvatures  and  make  its  walls  par- 
allel with  the  long  axis  of  the  tooth.  Covering  with  wax  the 
under  surface  of  the  crown-plate  should,  however,  be  avoided, 
as  it  is  desirable  to  have  that  rest  firmly  upon  the  column  of 
plaster  which  will  be  found  as  a  part  of  the  cast  after  the  wax 
has  been  softened  and  the  cap  withdrawn. 


Fig.  276. 


"  Upon  the  cast  thus  prepared  a  rim  of  wax  attached  to  a 
paraffine  and  wax  base-plate  is  modeled  preparatory  to  taking 
the  articulation.  The  details  of  this  method  do  not  at  all 
differ  from  the  methods  described  elsewhere  in  this  work. 

"The  base-plate  and  wax  rim  are  made  to  rest  upon  the 
cuspid  caps,  both  when  they  are  on  the  cast  and  when  in  the 
mouth,  to  which  they  are  restored  when  the  bite  is  taken. 

"  At  the  point  where  the  wax  rim  rests  upon  the  cuspid 
caps,  it  should  not  extend  beyond  their  labial  edge.  The 
articulation  and  an  impression  and  cast  of  the  lower  antago- 


BRIDGE    WORK. 


529 


nizing  teeth  being  secured,  tlie  cast  is  properl)-  mounted  upon 
an  articulating  frame. 

"Suitable  porcelain  teeth  are  now  to  be  selected  and 
mounted.  For  the  incisors  and  cuspids  plain  plate  teeth  are 
usually  selected  ;  they  should  be  strong  and  well  made.  The 
molars  and  bicuspids  are  built  up  almost  entirely  in  solid  gold, 
and  are  sometimes  made  throughout  of  that  metal ;  but  usu- 
ally porcelain  facings  are  employed,  which  at  least  serve  to 
protect  the  gold  from  view,  its  conspicuousness  being  objec- 
tionable. 

"  F'or  bicuspid  facings  cuspid  teeth  strongly  made  and  with 
heavy  pins  may  be  used.  In  fitting,  only  the  outer  edge  of  the 
necks  of  the  teeth  should  be  allowed  to  rest  upon  the  gum.  The 
teeth  should  be  so  spaced  that  the  cuspids  will  come  into  proper 
position  upon  the  caps  prepared  for  them.  In  fitting  them  to 
the  caps  the  utmost  nicety  should  be  observed,  so  that  there 
may  be  no  space  left  between  the  tooth  and  the  cap. 

"  If  the  front  of  the  cap  is  above  the  level  of  the  gum,  and 
thus  e.xposed  to  view,  it  can  often  be  concealed  by  bringing 
the  neck  of  the  porcelain  tooth  over  it,  using  very  small 
corundum  wheels  to  grind  out  on  the  under  surface  of  the 
porcelain  a  concave  space  adapted  to  the  conve.xity  of  the  cap; 
by  this  means  the  cap  can  often  be  perfectly  concealed  from 
view  by  a  film  of  porcelain  which,  although  thin,  will  in  that 
position  rarely  be  fractured. 

"The  teeth  being  fitted  into  position  on  the  model,  a  matrix 
in  two  sections  is  run  over  their  outer  surface,  and  upon  the 
outer  face  of  the  cast,  on  which,  as  guides,  conical  depressions 
are  previously  cut.  The  matrix  is  seen  as  D  in  Fig.  277.  The 
teeth  can  be  taken  from  it  and  returned  to  it  at  pleasure — a 
great  convenience  in  subsequent  processes. 

"As  molar  and  bicuspid  facings  are  subjected  to  great  strain 
when  mounted  upon  a  rigid  and  unyielding  piece  of  bridge 
work,  it  is  generally  desirable  to  shield  them  from  pressure  by 
a  heavy  gold  crown  plate;  this  can  be  made  in  precisely  the 
same  manner  as  previously  directed  for  making  the  crown 


230 


OPERATIVE    DENTISTRY. 


plate  for  the  molar  caps.  As  the  shell  of  the  crown  plate  fol- 
lows the  dimensions  of  a  natural  tooth,  and  molar  facings  are 
usually  much  narrower,  it  is  necessary  to  make  the  shell  and 
facing  correspond  in  width ;  this  is  readily  accomplished  by 
bending  in  the  edges  of  the  shell  to  the  necessary  extent  with 
a  pair  of  pliers.  The  palato-buccal  diameter  of  the  shell 
should  also  be  reduced,  as  it  is  rarely  desirable  to  make  arti- 
ficial molar  teeth  of  any  kind  the  full  size  of  the  natural  organs. 
The  shell,  being  thus  prepared,  is  filled  with  i8-carat  gold  and 
a  box  plate  attached  precisely  as  previously  described  for  the 
crown  plate  of  the  molar  tooth. 

Fig   277. 


",The  porcelain  molar-facing  upon  which  it  is  to  rest  is  then 
ground  away  sufficiently  to  allow  the  crown  plate  to  slip  in 
between  it  and  the  occluding  teeth,  as  seen  in  Fig.  280. 

"  Letter  A  is  the  porcelain  face  cut  down  at  B  to  admit  crown 
plate  C,  which  is  being  passed  into  position  between  the 
porcelain  face  and  the  occluding  tooth ;  it  is  the  plaster  matrix 
which  holds  the  teeth  in  position  upon  the  cast  when  the 
articulating  frame  is  reversed.  As  represented  in  the  cut  they 
would  drop  out. 

"  Too  much  care  cannot  be  exercised  in  making  the  joint 


'    HKIIXiK    \Vf)KK.  231 

between  the  porcelain  facing  and  the  crown  plate  a  perfect  one. 
For  artistic  effect,  and  also  for  cleanliness,  there  should  be 
absolutely  no  space  at  any  point.  To  secure  this  result,  it  is 
well,  after  all  but  the  finest  irregularities  have  been  removed 
by  the  corundum  wheel,  to  place  a  little  wet  pulverized  corun- 
dum between  the  two  surfaces  and  rub  them  together.  This, 
if  skillfully  done,  will  make  an  almost  impermeable  joint.  In 
fitting  to  position  allow  the  crown  plate  to  project  a  very 
little  beyond  the  buccal  surface  of  the  porcelain  facing.  This 
projection  is  to  be  cut  awa\'  in  finishing,  and  gives  a  little 
margin  for  perfecting  that  process. 

"After  the  same  manner  crown  plates  are  prepared  for  the 
other  molars  and  bicuspids,  which  teeth  are  then  removed 
from  their  matrices  and  backed  with  platinum  No.  27  standard 
gauge.  Each  backing  is  made  to  extend  from  the  grinding 
surface,  when  it  is  brought  in  close  contact  with  the  crown 
plate,  to  the  extreme  edge  of  the  neck,  and  to  cover  the  entire 
inner  surface  of  the  tooth  from  side  to  side.  It  must  be 
adapted  to  the  porcelain  surface  with  the  utmost  nicety.  The 
platinum  being  pliable,  can  be  bent  and  burnished  into  the 
closest  contact;  so  that  the  joint  shall  be  impermeable.  The 
proximal  and  cervical  margins  are  bevelled  down  to  a  feather 
edge  ;  the  coronal  margin  is  left  square.  (The  facing  as  thus 
prepared,  with  its  crown  plate  and  backing,  is  seen  in  Fig.  278.) 
Cement  is  then  placed  between  the  crown  plate  and  backing 
and  the  tooth  invested  in  the  marble-dust  and  plaster  mixture 
already  recommended,  preparatory  to  soldering  the  platinum 
pins  of  the  porcelain  facing  to  the  backing  and  the  backing  to 
the  crown  plate,  at  the  same  time  filling  in  solidly,  with  metal, 
the  angle  between  the  latter  two.  It  is  an  economy  of  time 
and  labor  to  place  three  or  four  teeth  in  the  same  inx^estmcnt, 
taking  care  that  sufficient  space  is  left  between  them  to  prevent 
union.  Invested  in  this  manner  the  teeth  will  present  the 
appearance  presented  in  Fig  279.  The  dotted  lines  seen  in 
Fig.  280  indicate  the  surface  to  which  the  gold  is  extended  in 
the  soldering  process. 


232  OPERATIVE    DENTISTRY. 

"  In  soldering  great  care  must  be  taken  to  secure  a  uniform 
temperature  throughout  the  investment  and  its  enclosed  teeth  ; 
such  large  masses  of  metal  are  to  be  imposed  upon  the  porce- 
lain facings  that  unless  the  utmost  caution  is  observed  there 
is  great  danger  of  fracture.  The  safest  plan  is  to  heat  the 
investment  to  a  dull-red  heat  over  a  gas-stove  or  other  suit- 
able heating  apparatus,  and  then  transfer  it  to  a  hot  bed  of 
charcoal  in  the  soldering  furnace ;  by  this  means  the  heat  can 
be  raised  gradually  and  uniformly  and  be  maintained  at  the 
required  point  throughout  the  soldering  process. 

"  If  the  blowpipe  flame  alone  is  depended  upon,  there  is 
always  the  danger  that  the  face  of  the  porcelain  teeth  next  to 


Fig.  278. 


Fig.  28 


the  metallic  backing  will  be  heated  to  a  much  higher  point 
than  that  in  contact  with  the  investment,  unequal  expansion, 
followed  by  fracture,  being  pretty  sure  to  result.  With  single 
teeth  fracture  in  soldering  does  not  usually  depend  upon  too 
rapid  heating  or  too  rapid  cooling,  but  rather  upon  unequal 
heating  and  cooling.  A  good  porcelain  single  tooth  protected 
from  direct  contact  with  flame  by  a  suitable  investment  can  be 
.safely  raised  to  a  full  red  heat  in  five  minutes,  and  cooled  to 
the  temperature  of  the  air  in  as  many  more,  provided  that  care 
be  taken  to  make  the  application  of  heat  uniform  and  progres- 
sive. If  a  pointed  blowpipe  flame  at  perhaps  the  tempera- 
ture of  2000°  F.  is  thrown   upon  that  face  of  the  porcelain 


BRIDGE    WORK.  233 

covered  by  the  backing,  while  the  other,  covered  by  a  thick 
investment,  remains  at  a  temperature  not  much,  if  at  all,  above 
212°  F.,  as  indicated  by  the  still-escaping  steam  from  the  plas- 
ter, fracture  is  sure  to  result.  The  thicker  the  investment  the 
more  difficult  does  it  become  to  equalize  the  temperature  on 
both  sides  of  the  porcelain  tooth.  For  this  reason  it  is  rarely 
desirable  to  make  the  investment  more  than  half  an  inch  in 
thickness. 

"  The  description  just  given  of  the  methods  of  making  molar 
and  bicuspid  bridge-teeth  must  be  slightly  modified  for  the 
left  molar  bridge-tooth,  to  which  the  bar  already  shown  (Fig. 
270)  is  to  be  attached. 

"  To  this  molar  the  mesial  end   of  the  bar  is  cemented,  the 

Fig.  281.  Fig.  282. 


bar  being  placed  against  the  backing  and  beneath  the  crown- 
plate,  as  seen  in  Fig.  281. 

"  The  angle  between  the  backing  and  crown-plate  being  filled 
with  wax-and-rosin  cement,  the  bar  will  be  strongly  held,  and 
while  the  cement  is  still  plastic  the  tooth  and  bar  are  conveyed 
to  position  in  the  mouth  and  the  adjustment  of  the  bar  to  the 
slot,  and,  at  the  same  time,  of  the  crown-plate  to  occlusion,  is 
preferable.  The  cement  is  then  chilled  and  the  tooth  invested 
and  soldered  as  before  described.  The  investment  grasps  the 
distal  end  of  the  bar  and  holds  it  in  position  after  the  cement 
has  melted,  while  the  gold  solder  takes  the  place  of  the 
cement  and  holds  the  bar  firmly  and  rigidly  in  place. 

"  Fig.  282  gives  a  sectional  view  of  the  completed  typical 
bridge-tooth,  porcelain  seen  in  Fig.  281  having  been  filed 
16 


234  OPERATIVE    DENTISTRY. 

away  to  a  level  with  the  buccal  surface  of  the  facing.  The 
relation  to  the  alveolar  ridge  of  the  cervical  edge  of  the 
bridge-tooth  when  in  position  is  shown  in  the  diagram.  All 
exposed  surfaces,  except  the  coronal,  form  inclined  planes, 
upon  which  it  is  impossible  for  food  to  lodge  or  remain. 

"As  the  contracted  cervical  edge  barely,  if  at  all,  touches  the 
gum,  it  affords  no  obstacle  to  the  flushing  effect  of  water  held 
in  the  mouth  and  washed  to  and  fro  under  the  denture.  All 
the  broader  surfaces  are  readily  accessible  to  a  properly-con- 
structed brush.  The  molar  and  bicuspid  bridge-teeth  being 
completed,  the  cuspids  and  incisors  also,  are  to  be  backed  and 
soldered.  Platinum  backings  should  be  used  for  each,  and 
the  solder  should  be  i8-carat  gold  plate.  In  soldering  the 
cuspids  the  palatine  surface  should  be  filled  out  to  contour,  as 


seen  in  Fig.  283.  The  two  cuspids  may  be  soldered  in  one 
investment,  and  the  four  incisors  in  another.  Upon  the  back- 
ing of  each  incisor  a  large  excess  of  gold  should  be  flowed, 
as  seen  in  Fig.  284,  where  it  is  made  about  the  twelfth  of  an 
inch  in  thickness.  If  it  is  found  desirable  to  have  a  shoulder 
upon  the  inner  edge  of  the  incisor  for  occlusion  with  the  lower 
teeth,  this  can  readily  be  secured  by  cementing  a  strip  of  22- 
carat  gold  at  the  proper  point  transversely  across  the  backing, 
as  seen  in  Fig.  285,  and  flowing  in  gold  up  to  the  dotted  lines. 
The  several  pieces  of  the  bridge  being  now  completed,  all 
that  remains  is  first  to  unite  them  into  sections,  and  then  join 
the  sections,  thus  constituting  a  continuous  arch.  The  first 
section  will  be  composed  of  the  right  cuspid  and  molar  abut- 
ment-teeth   and    the    three    intermediate    bridge-teeth.      The 


BRIDGE    WORK.  235 

second  section  will  be  formed  of  the  left  cuspid,  the  left 
molar,  with  the  anchorage-bar  attached  and  the  intervening 
bicuspids.  The  third  section  will  consist  of  the  four  incisors 
only. 

"To  build  the  sections,  the  teeth  composing  them  are  re- 
stored to  their  several  positions  in  the  matrix  upon  the  cast, 
the  sides  of  the  crown-plates  and  metallic  backings,  if  redun- 
dant, being  cut  down  sufficiently  to  allow  the  teeth  to  rest 
side  by  side  in  the  matrices.  It  is  desirable  that  the  edges  of 
the  crown-plate  should  be  fully  in  contact,  but  that  the  back- 
ings should  touch  only  toward  the  buccal  surfaces  of  the 
several  teeth,  from  tliose  points  to  the  palatine  edges  of  the 
backing  narrow  V-shaped  spaces  should  be  left,  into  which  the 
solder  will  readily  flow  and  thus  ensure  the  effectual  filling  up 
of  the  joint,  and  consequently  the  firm  and  strong  union  of 
the  several  teeth  and  caps  Avhich  compose  the  section.  After 
being  satisfactorily  arranged  in  the  matrix,  the  teeth  and  caps 
are  strongly  cemented  together  with  a  brittle  wax-and-resin 
cement,  and  transferred  to  position  in  the  mouth  when  the 
final  adjustments  are  perfected. 

"  The  cement  is  then  chilled.  In  this  state  it  should  be  quite 
strong  enough  to  hold  together  the  several  parts  of  the  sec- 
tion. But,  usualh\  such  cements  are  not  strong  enough  to 
withstand  the  strain  necessarily  put  upon  them  in  withdraw- 
ing tightly-fitting  caps  from  anchorage-teeth.  In  such  cases 
a  thin  matri.x  should  be  moulded  over  their  buccal  surfaces 
as,  held  together  by  the  cement,  they  stand  in  position  in  the 
mouth.  This  matrix  should  be  made  of  a  quickly-setting 
plaster  mixed  to  a  thick  batter.  It  is  to  be  spread  by  a 
spatula  over  the  entire  front  of  the  section,  that  surface  of  each 
tooth  and  cap  composing  it  being  fully  covered,  the  plaster 
at  the  same  time  being  run  well  into  the  interspaces.  After 
the  plaster  has  hardened,  the  matrix  is  removed  from  the 
mouth,  as  also  are  the  teeth  and  caps.  These,  on  being 
replaced  in  the  section  matrix,  are  there  held  in  precisely  the 
same  relative  position  which  they  occupied  in  the  mouth. 


236 


OPERATIVE    DENTISTRY. 


"  Bridge-teeth  and  anchorage-caps  are  then  very  strongly 
cemented  together  and  the  cement  thoroughly  chilled,  to 
avoid  the  possibility  of  bending.  The  section  is  then  care- 
fully lifted  from  the  matrix,  invested,  grinding  surfaces  down, 
in  the  marble-dust-and-plaster  investment,  and  soldered  with 
the  zinc  alloyed  i8-carat  solder  previously  recommended. 

"  Fig.  286  shows  the  right  section  thus  invested.  The  same 
methods  are  to  be  employed  in  forming  the  other  sections. 

"  Finally,  the  three  sections  must  be  joined,  to  form  the  con- 
tinuous arch.     The  point  of  junction  will  be  between  the  cus- 

FlG.  286. 


pids  and  laterals  of  either  side.  These  two  points  must  first 
be  strongly  cemented.  This  is  best  accomplished  by  thor- 
oughly drying  the  right  and  left  sections,  and  then  placing 
them  in  position  in  the  mouth,  where,  by  means  of  napkins, 
they  must  be  carefully  protected  from  moisture.  The  incisor 
section  is  then  also  dried  and  slightly  heated.  The  distal  sur- 
faces of  the  lateral  incisors  is  covered  with  quite  a  thick  layer 
of  the  wax-and-resin  cement,  and  while  this  is  still  soft  and 
adhesive,  the  section  is  carried  to  the  mouth  and  pressed  into 
place,  where  the  cement  serves  to  attach  it  to  the  other  sec- 
tion.    If  the  adhesion  is  not  satisfactory,  it  can  be  improved 


BRIDGE    WORK.  237 

by  rcmelting  the  cement  with  a  liot  iron,  at  the  same  time  the 
surfaces  to  be  joined.    The  cement  siioukl  then  be  chilled. 

"  A  matrix  is  then  made  somewhat  after  the  manner  of  taking 
an  impression,  the  plaster  being  allowed  to  cover  the  teeth, 
previously  slightly  oiled,  for  about  one-third  their  length 
above  the  cutting-edges  and  grinding-surfaces,  as  seen  in  Fig. 
287.  The  impression-tray  is  shallow  and  need  contain  only 
a  small  amount  of  plaster. 

Fig.  287. 


"The  matrix  must  be  trimmed  away  until  the  bridge-piece 
can  easily  be  detached  and  be  replaced  or  withdrawn  with 
perfect  freedom.  If  the  cement  between  the  cuspids  and 
laterals  has  been  fractured,,  it  must  be  again  restored  and 
hardened.  The  case  is  then,  with  the  most  scrupulous  care 
and  delicacy  of  manipulation,  lifted  from  its  place  in  the 
matrix  and  transferred,  crown  side  up,  to  the  investment-slab 
seen  in  Fig.  288,  which  is  designed  to  give  a  rigid  and  fixed 


238 


OPERATIVE    DENTISTRY. 


support  to  the  bridge-piece  and  its  investment,  and  thus  pre- 
vent warpage  of  the  one  or  fracture  of  the  other  during  the 
soldering  process. 

"The  investment-slab  is  made  of  fireclay,  about  one-fifth  of 
an  inch  in  thickness,  its  other  dimensions  corresponding  to 
those  of  the  case  to  be  invested.  On  its  outer  circumference 
are  placed  dovetailed  notches,  made  larger  on  the  under  than 
the  upper  surface  of  the  slab.  These  serve  as  anchorage  for 
the  investment  and  prevent  its  breaking  away  from  the  case  or 


Fig.  28 


from  the  slab.  In  investing,  those  notches  are  filled  with  the 
investment  mixture  (beach-sand  and  plaster-of-Paris,  equal 
parts),  and  at  the  same  time  a  sufficient  amount  of  the  material 
is  heaped  up  upon  the  slab  (previously  placed  upon  a  flat, 
smooth  surface)  securely  to  imbed  the  bridge-piece  as  it  is 
transferred  from  the  matrix. 

"All  parts  of  the  case,  except  immediately  around  the  sur- 
faces to  be  soldered,  are  covered  with  the  investment,  which, 
as  already  stated,  need  at  no  point  be  more  than  half  an  inch 
in  thickness. 


BRIDGE    WORK. 


239 


"  Fi^.  289  shows  the  iiucstcd  case,  a  is  the  in\'estiiient ;  li, 
the  iinestinent-slab ;  c,  c,  tlie  joints  to  be  closed.  It  need 
liardl}'  be  stated  that  in  this  final  soldering  the  same  care  in 
regulating  the  temperature  should    be   observed  as  has  been 


Fk: 


previously  directed.  In  this  soldering  the  zinc-alloyed  gold 
solder  should  be  used  and  the  joint  between  the  laterals  and 
cuspids  on  either  side  should  be  fully  filled.  After  cooling, 
the  case  is  then  ready  for  the  final  finishing  processes  and  for 
adjustment  in  the  mouth. 

Fig.  290. 


"  Fig.  290  shows  the  completed  case  detached  and  in  Fig. 
291  it  is  seen  in  position. 

"  If  the  directions  gi\'en  for  the  construction  of  the  cases  of 
bridge-work   have  been  carefully  followed,  the  denture,  after 


240 


OPERATIVE    DENTISTRY. 


the  final  soldering  and  finishing,  should  pass  up  into  position 
in  the  mouth  and  fit  with  perfect  accuracy. 

"  Any  warpage  indicates  defective  manipulation.  This  fault 
is  readily  detected  by  testing  the  case  in  the  final  matrix  (Fig. 
287),  in  which  it  should  fit  as  perfectly  after  as  before  invest- 
ment and  soldering,  except  that  a  little  excess  of  solder  in  the 
joints  between  the  incisors  and  cuspids  may  cause  a  mal- 
adjustment at  those  points — a  fault,  however,  easily  discovered 
and  remedied,  either  by  removal  of  the  solder  or  by  scraping 

Fig.  2QI. 


away  the  plaster  of  the   matrix;   which  being  done  the  case 
will  go  fully  into  place. 

"  In  placing  the  completed  arch  upon  the  anchorage-teeth 
some  difficulty  may  arise  in  consequence  of  a  want  of  coinci- 
dence in  their  respective  angles  of  inclination.  This  is  a 
detail  which  must  be  looked  to  before  determining  the  plan  of 
the  bridge,  and  the  case  should,  as  far  as  possible,  be  con- 
structed with  a  view  to  avoiding  the  complication,  such 
anchorages  being  selected  as  will  accomplish  this  end,  and  at 
the  same  time  be  satisfactory  in  other  respects. 


LOW  i5KID<;k.  241 

"  With  every  care,  however,  it  may  sometimes  happen  that 
while  the  individual  sections  are  readily  adjustable  to  their 
respective  anchora;j^es,  they,  when  united,  interlock  in  such  a 
way  that  either  removal  or  replacement  is  difficult  or  imprac- 
ticable. This  is  a  point  which  b\'  the  aid  of  the  final  matrix 
can  and  should  be  fully  tested  before  the  sections  are  united 
by  solder  ;  for  the  plaster  of  the  matrix  holds  them  firmly 
together,  and  if  while  thus  held  in  contact  they  cannot  be 
withdrawn  from  their  respective  anchorages,  or,  being  sepa- 
rately withdrawn  and  restored  to  their  relative  positions  in  the 
matrix,  they  cannot  be  replaced  upon  the  anchorage-teeth,  it 
is  entirely  inadvisable  to  proceed  farther  until  the  difficulty  is 
remedied. 

"Usually,  this  can  readily  be  accomplished  by  cutting  away 
that  face  or  angle  of  the  anchorage-tooth  or  root  which  is 
the  point  of  difificulty.  Sometimes  the  simple  shortening  of 
the  retaining-pins,  or  the  enlargement  in  a  given  direction  of 
one  or  more  of  the  pulp-canals,  will  overcome  the  trouble. 
To  precisely  locate  the  points  of  interference,  the  surface  of 
the  implicated  teeth  or  roots  may  be  covered  with  a  thin  film 
of  wax,  or  the  edge  and  inner  surface  of  the  ferrules  may  be 
covered  with  a  layer  of  rouge  or  plumbago,  which  will  leave 
a  distinct  mark  upon  the  anchorage-teeth  at  whatever  points 
pressure  is-  most  considerable,  which  points  being  then  cut 
away,  the  denture  may  readily  pass  into  place.  All  remedial 
measures  of  this  kind  failing,  some  modification  of  the  plan  of 
construction  of  the  denture,  of  a  nature  to  simplify  its  anchor- 
ages, will  be  necessary."* 

Low  Bridge. — "  For  the  first  illustration,  as  seen  in  Fig. 
292,  we  have  a  case  where  all  the  teeth  have  been  extracted 
except  the  two  cuspids  and  two  second  molar  roots. 

"  We  first  proceed  to  prepare  the  roots  by  crowning.  I  use 
gold  crowns  on  the  molar  teeth  and  the  Low  crown  on  the  two 
cu.spids. 

*"  Am.  Syst.  Dent.,"  II,  846, 


242 


OPERATIVE    DENTISTRY. 


"  The  preparation  of  the  two  cuspids  consists  in  making  the 
crown  read}'  for  adjustment.  I  always  measure  the  tooth  to 
be  crowned  with  gold  with  a  strip  of  block  tin,  about  35  Stub's 
gauge.  Place  the  tin  around  the  tooth,  and  with  pliers  care- 
fully measure  the  full  size  of  the  same. 

"  Should  you  be  measuring  a  tooth  or  part  of  a  tooth  on 
which  there  are  projections,  take  the  engine  and  with  a  stone 
grind  off  the  same,  making  a  smooth  surface,  so  there  will  be 
nothing  to  interfere  with  the  proper  fitting  of  the  bands.  After 
cutting  the  tin  measures  by  the  marks  made  by  the  pliers,  you 

Fig. 292. 


have  the  measures  ready  to  make  the  gold  bands  by.  Cut 
the  bands  and  bevel  the  edges  and  solder  together,  and  you 
are  ready  to  fit.  After  fitting  all  the  bands  and  finishing  the 
crowns  in  the  usual  way,  I  place  each  in  position  in  the  mouth, 
having  previously  regulated  the  articulation  of  each  crown  as 
desired  in  the  process  of  making.  I  now  take  a  deep  articula- 
tion in  wa.x  and  impression  in  plaster  of  Paris  ;  remove  before 
it  gets  too  hard,  and  place  all  the  crowns  in  their  positions  in 
the  impression;  varnish,  oil,  and  pour  in  the  usual  way; 
separate  the  cast  from  the  impression  and  place  in  the  ar- 


LOW    HRinCE.  243 

ticulator.  Then  pour  plaster.  After  the  plaster  has  hardened, 
remove  the  wax,  and  we  have  the  articulation  proper  and  are 
ready  to  select  and  grind  our  teeth,  having  previously  selected 
our  shade.  My  experience  has  long  ago  taught  me  that  no 
porcelain  teeth  can  stand  the  pressure  for  bridge  work,  the 
strain  on  them  being  twice  as  great  as  with  teeth  on  plates, 
which  rest  on  the  gums,  that  gi\e  to  pressure.  In  order  to 
prevent  breakage  of  teeth  and  give  strength,  I  have  for  many 
years  been  making  a  tooth  with  gold  cusps.  I  will  here 
describe  my  manner  of  doing  so. 

"  I  had  some  shells  of  bicuspids  and  molars  made,  or  rather 
teeth,  without  the  crown.  They  can  now  be  found  in  some 
of  the  depots.  For  the  first  step  I  use  28-gauge  platinum  for 
a  covering  of  the  inside  of  the  shell,  or  just  where  you  wish 
gold  to  flow.  Then  I  bend  the  pins  down  to  hold  the  pla- 
tinum in  position,  and  with  a  file  remove  all  overlapping  pla- 
tinum to  prevent  breaking  of  our  teeth  in  heating.  The  tooth 
is  made  flat  on  the  crown  surface  with  the  express  intention 
of  restoring  with  a  gold  crown.  The  crown  need  not  be  very 
thick,  but  should  perfectly  resemble  the  cusps  on  the  natural 
tooth  for  the  purpose  of  mastication.  As  these  cusps  are  not 
on  the  market,  and  every  dentist  making  bridge  work  cannot 
make  it  in  a  way  to  stand  without  putting  gold  cusps  on  the 
grinding  surface  of  the  bicuspids  and  molars,  I  will  here 
describe,  for  the  benefit  of  those  who  do  not  know  how  to 
make  them,  how  they  can  be  made  with  very  little  trouble. 
Pick  out  a  natural  tooth  with  cusps  the  exact  shape  you  wish 
to  have  your  gold  cusp;  mix  some  fireclay  in  a  thick  paste, 
then  press  your  tooth  into  it  a  little  deeper  than  you  wish  the 
cusps.  Having  made  the  proper  impression,  remove  the  tooth, 
and  set  the  impression  over  the  gas  stove  to  dry.  After  it  is 
dried  and  reasonably  hot,  lay  your  pieces  of  gold  in  the 
impression  and  with  a  blowpipe  melt  them.  When  melted, 
press  with  a  piece  of  steel  on  the  gold  till  cool.  This  mould 
will  do  to  make  many  from.  If  you  have  not  the  fireclay,  and 
can  get  charcoal  that  is  burned  from  fine-grained  wood,. and  is 


244 


OPERATIVE    DENTISTRY. 


soft,  you  can  simply  press  your  tooth  into  the  charcoal  and 
melt  in  the  same  way,  or  you  can  carve  your  teeth  as  you 
desire  in  a  block  of  carbon.  Of  course,  the  little  steel  dies 
are  handier,  as  we  can  swage  up  our  gold  cusps  in  them,  either 
solid  or  thin. 

"  Having  described  our  manner  of  making  the  cusps,  we  will 
now  return  to  the  manner  of  finishing  our  tooth.  I  left  off 
by  saying  we  covered  the  inside  and  bent  down  the  pins  and 
filed  off  the  overlapping  platinum.  We  now  place  the  cusp  on 
the  top  of  the  tooth,  and  place  in  the  position  desired,  holding 
it  there  with  wax,  and  with  a  spatula  trim  the  wax  the  exact 
shape  we  wish  our  tooth  to  be — V  shape,  tapering  from  the 
crown  down.  We  now  encase  in  plaster  and  sand,  which  gives 


Fig.  293. 


Fig.  294. 


US  a  box.  When  hard  remove  the  wax  and  place  over  the 
stove,  and  when  sufficiently  dry,  fill  in  with  coin  gold,  using 
the  blowpipe  to  melt  it  in  a  solid  mass,  and  then  our  tooth 
is  ready  to  fill  up  and  place  in  position  on  the  articulator. 
Fig.  293  shows  the  tooth  in  this  condition. 

"After  our  teeth  are  all  arranged  we  hold  the  same  in  posi- 
tion with  wax,  remove  from  the  articulator,  encase  with  plaster 
and  sand  or  asbestos  in  the  usual  way.  That  we  may  have  a 
strong  case,  I  always  use  platinum  wire  between  all  the  teeth, 
and  then  proceed  to  heat  and  solder.  Be  sure  all  the  gold 
cusps  are  so  arranged  that  you  can  get  all  soldered  together, 
as  this  gives  us  great  strength.  My  formula  for  solder,  which 
I  have  used  for  many  years,  and  which  will  be  found  very  easy 


LOW    I5KIDGE. 


245 


flowing  aiul  almost  the  exact  color  of  the  gold  you  are  using, 
is  as  follows  (always  figure  fiom  the  carat  of  gold  you  arc 
working) :  Take  one  pennyweight  of  coin  gold,  two  grains  of 
copper,  and  four  of  silver.  We  now  have  our  case  soldered; 
after  filling'  as  desired,  commence  to  finish  with  felt  wheels  and 
pumice-stone,  after  which  use  rough  buff  wheels.  We  are 
now  ready  to  adjust  in  the  mouth.  In  Fig.  294  we  see  the 
case  ready  for  adjustment. 

"  Have  the  assistant  dry  all  the  teeth  or  roots  to  be  operated 
upon  while  you  are  mi.xing  the  cement.  Be  sure  and  use  a 
kind  which  does  not  harden  very  rapidly,  or  your  cement  will 
set  before  you  get  your  teeth  adjusted.     Use  sufficient  cement 

Fig.  295. 


to  fill  all  the  gold  crowns  perfectly  when  the  case  is  driven  to 
place.  Moisten  the  step  plugs  and  cap  with  cement,  touching 
every  portion,  and  with  an  instrument  place  a  little  cement  in 
the  bottom  of  the  cavity.  We  now  adjust  our  case,  using  the 
little  rotor  for  the  Low  crowns  and  a  piece  of  ivory  for  driv- 
ing on  the  gold  crowns.  Fig.  295  represents  the  case  when 
in  position. 

"  It  will  be  seen  by  looking  at  Fig.  294  that  the  teeth  after 
having  been  soldered  are  all  spaced  fully  one-third  of  the  dis- 
tance from  the  place  of  contact  with  the  gums  and  the  grinding 
surface  of  the  teeth,  so  that  the  secretions  could  not  possibly 
lodge  there.     I  have  given  you  a  description  of  my  manner  of 


246 


OPERATIVE    DENTISTRY. 


making  a  full  upper  case  of  bridge  work  where  there  are  roots 
to  be  crowned  to  support  the  bridge.  I  will  now  describe  my 
manner  of  operating  upon  a  case  where  the  four  centrals  are 
missing,  as  seen  in  Fig.  296.  To  supply  these  four  teeth 
where  the  cuspids  are  intact,  I  use  a  gold  band.  I  first 
measure  the  tooth  with  strips  of  tin,  and  make  the  gold  bands, 
as  before  described,  and  cut  out  the  outside  lower  portion  ot 
the  band  before  beginning  to  fit.  In  fitting,  as  the  band  is 
being  driven  down,  cut  away  any  of  the  band  that  touches 
the  gum  before  all  touches  ;  never  drive  the  band  under  the 
gum,  as  inflammation  would  probably  follow. 

Fig.  296. 


"  I  mention  this  as  I  have  seen  many  attempts  to  get  rid  ot 
the  bands  by  driving  up  under  the  gums  and  cutting  them 
out  on  the  front,  until  they  were  too  narrow  for  strength.  It 
is  hard  work  to  make  something  out  of  nothing.  The  bands 
should  be  heavy  and  strong,  and  the  patient  made  to  under- 
stand that  if  he  expects  to  get  rid  of  the  annoyance  of  the 
plate  he  must  sacrifice  his  dislike  to  showing  gold.  After 
driving  the  bands  up  close  to  the  margin  of  the  gums,  as  the 
cuspid  teeth  are  very  tapering,  the  bands  will  have  to  be 
taken  in  at  the  bottom.  To  do  this,  I  slit  the  band  about  a 
third  of  its  length   up,  then  place  it  on  the  tooth  again,  lap  it 


I.oW     liKllXiE. 


247 


over  enough  to  biiiiL^  it  to  a  close  fit,  and  then  take  it  off  and 
solder, 

"  Continue  taking  it  in  wherever  it  does  n(jt  perfectly  fit  the 
tooth,  and  after  a  good  fit  is  obtained,  j)roceed  as  before 
described,  by  taking  an  articulation  and  impression.  In  adjust- 
ing, first  try  the  case  on  to  see  that  it  fits,  and  that  the  articula- 
tion is  all  right.     Fig.  297  shows  the  case  ready  for  adjustment. 

"  Next  have  the  assistant  dr\'  the  teeth  ui)on  wliicli  the 
bands  are  going,  and  then  mix  )'our 
cement.  This  should  be  mixed  to 
about  the  consistency'of  thick  cream. 
It  must  be  neither  too  thick  nor  too  ^^m»  IL 
thin,  or  the  adhesion  will  not  be 
strong    enough    to    hold.       Cover 

your  ^teeth  with  cement,  and  then  the  inside  of  the  bands. 
Place  these  on  the  teeth  and  carefully  mallet  up  into  position. 
For  this  purpose  I  use  a  steel  instrument  with  a  crease  or 
groove  in  the  end.  The  teeth  must  be  kept  dry  after  the  case 
is  in  position  until  the  cement  is  well  set.      After  this  is  done, 


Fig.  297. 


Fig.  298. 


bevel  the  edges  of  the  bands  and  burnish  close  to  the  teeth, 
and  if  properly  done  they  will  be  made  to  resemble  gold  fill- 
ings.    In  Fig.  298,  we  have  the  case  completed. 


248  OPERATIVE    DENTISTRY. 

"  I  am  aware  that  in  a  case  like  this,  porcelain  crowns 
instead  of  gold  bands  could  be  used,  and  I  should  consider  it 
much  preferable  to  do  so  where  we  have  roots  or  unsound 
teeth  to  operate  upon  ;  but  I  do  not  advise  the  destroying  of 
nerves,  where  the  teeth  are  intact,  to  supply  such  a  case  with 
crowns,  as  the  bands  will  answer  every  purpose  for  many 
years. 

"  If  they  should  give  out  in  after  years,  the  roots  can  then 
be  crowned.  I  have  many  of  these  cases  that  have  been  in 
use  seven  and  eight  years,  some  of  which  have  never  loosened, 
and  some  I  have  reset  nearly  every  year.  I  always  impress 
upon  the  patient  the  necessity  of  having  them  reset  immedi- 
ately should  they  become  loose,  and  advise  them  to  have  their 
cases  examined  at  least  once  a  year.  Should  parties  insist  upon 
having  crowns  used  to  supply  a  case  like  the  one  just 
described,  on  perfectly  sound  teeth,  I  should  begin  by  using  an 
aluminum  disk  with  corundum,  cutting  deep  as  possible  both 
on  the  labial  and  lingual  sides,  and  then  use  the  excising  for- 
ceps. This  can  be  done  under  the  influence  of  an  anaesthetic 
or  otherwise.  It  is  not  by  any  means  so  painful  an  operation 
as  one  would  think.  If  the  nerve  does  not  come  out  with  the 
piece  of  tooth  cut  off,  I  take  a  piece  of  orange-wood,  which  I 
have  previously  cut  the  proper  shape,  to  drive  into  the  nerve 
canal.  I  place  it  in  creasote  and  let  it  soak  a  few  minutes 
before  beginning  to  operate.  Immediately  after  severing  the 
tooth  drive  this  into  the  canal,  then  remove  and  dip  in  crea- 
sote, and  drive  in  again.  This  will  perfectly  fill  the  nerve- 
canal;  all  sensitiveness  will  disappear,  and  you  can  begin  to 
operate  at  once.  I  do  not  recommend  this  treatment  for  sound 
teeth,  but  I  have  treated  many  exposed  nerves  in  this  way, 
also  many  teeth  broken  by  accident,  and  think  this  the  most 
satisfactory  way  to  dispose  of  such  cases.  I  have  never  had 
any  unfavorable  results  follow  after  operating  upon  teeth  in 
this  way,  and  I  can  hardly  say  as  much  in  favor  of  any  other 
treatment.  I  speak  of  this  manner  of  treating  exposed  nerves 
as  one  of  the  operations  that  sometimes  become  necessary  in 


LOW    IfKinOE. 


249 


adjusting  a  bridge  properly.  I  do  not  claim  any  originality  in 
this  mode  of  treatment.  I  know  several  dentists  who  u.se  this 
method,  all  of  whom  report  satisfactory  results.  We  now 
have  Fig.  299,  showing  the  roots  prepared  to  receive  the  case. 


I'll..  J'm. 


"  I  have  many  of  these  cases  in  use  that  arc  giving  entire 
satisfaction.  The  instrument  selected  for  preparing  these  roots 
should  be  one  with  small  inside  cutters  and  large  bevelers,  so 
as  not  to  cut  away  any  more  tooth  substance  than  possible. 


Fig.  300 


"Fig.  300  represents  the  case  ready  for  adjustment. 
301  represents  the  case  after  adjustment. 
17 


Fig. 


!50 


OPERATIVE    DENTISTRY. 


"In  this  article  I  have  described  my  manner  of  making 
teeth  for  bridge  work.  I  am  now  having  made  a  tooth  ex- 
pressly for  bridge  work,  which  I  hope  to  be  able  to  place  on 
the  market  soon.  I  have  been  using  these  teeth,  but  have  not 
perfected  my  shells  and  moulds  sufficiently  to  enable  me  to 
get  them  out  in  large  quantities. 

"  Fig.  302  shows  us  a  socket.  This  I  propose  to  have  ready 
made  in  various  sizes  in  bicuspids  and  molars,  with  corre- 
sponding shells.  Figs.  303  and  304  represent  the  shells  placed 
in  sockets.  Fig.  303  is  a  molar  tooth  showing  the  shell  in 
position,  and  Fig.  304  is  a  central  reversed.  Fig.  305  repre- 
sents the  socket  as  made  for  the  four  central  and  two  cuspid 
teeth.  The  advantage  of  these  teeth  can  readily  be  seen,  not 
only  for  bridge  work,  but  all  gold  plates.  A  tooth,  if  broken, 
can  readily  be  replaced  without  removing  the  bridge  or  crack- 


FlG.  302. 


Fig.  303. 


Fig.  304. 


Fig.  305. 


ing  by  soldering,  and  with  only  a  small  expense.  Fig.  306 
represents  the  shell  placed  in  position  in  the  socket,  which  can 
be  used  for  bridge  or  crown  work,  and  will  greatly  reduce  the 
labor  in  making  either."* 

Parmly  Brown  Bridge. — "  This  system  has  the  metal  baked 
invisibly  through  the  body  of  the  teeth.  No  metal  shows 
either  inside  or  outside  of  the  dental  arch.  The  six  anterior 
teeth  are  riveted  to  the  platino-iridium  bar  by  the  ordinary  pins 
of  plate  teeth,  which  are  the  teeth  used  for  this  work.  The 
bicuspids  and  molars  are  prepared  by  grinding  a  slot  on  the 
palatal  surfaces  of  the  teeth.  The  bar  (which  is  squared  for 
these  teeth,  instead  of  being  flattened  as  for  the  front  teeth)  is 
inserted  into  this  groove  or  slot,  which  should  be  ground  with 


*  "Am.  Syst.  Dent.,"  ii, 


PAKMLV    liUOWN    ltl<II)(iE. 


251 


a  thin  coriiiulum  wheel  to  fit  tlie  bar,  wliich  can  be  barbed  to 
make  i)roper  impingement.  It  is  then  ready  to  receive  the 
creamy  tooth  body,  which,  at  this  juncture,  is  appUed  to  tlie 
palatal  surfaces  of  all  the  teeth,  completely  covering  the  metal 
and  giving  the  natural  contour  to  the  inner  surfaces.  A  little 
of  the  tooth  body  is  allowed  to  run  between  the  teeth,  uniting 
their  approximal  surfaces.  In  this  work,  when  cross-pin  teeth 
are  used,  the  pins  will  be  ground  out  in  most  cases ;  but  if 
straight-pin  teeth  are  used,  the  pins  will  be  bent  over  the  bar. 
I  will  give  a  few  illustrations  of  the  many  ways  in  which  this 
work  can  be  done. 

"  F'S-  307  '^  ^  view  of  a  platino-iridium  bar  baked  on  to  a 
plain-plate  tooth,  by  first  riveting  the  flattened  baron  the  pins, 


Fig.  307 


Fig.  309. 


then  applying  tooth  body  to  the  back,  completely  covering  bar 
and  pins,  and  then  baking  in  a  continuous-gum  furnace.  The 
body  can  be  applied  readily  of  a  creamy  consistence,  and, 
after  being  held  a  moment  over  a  spirit-lamp,  is  ready  to  be 
put  on  the  slide  and  baked. 

"  Cavities  or  fillings  are  usually  found  on  either  side  of  a 
space  made  by  the  loss  of  a  tooth  or  teeth  that  will  allow  the 
insertion  of  the  ends  of  the  metal  bar  and  the  thorough 
impacting  of  gold  around  them.  Amalgam  can  be  used  in 
posterior  teeth  in  many  cases,  or  gold  crowns  penetrated  by 
the  bar,  as  in  Figs.  308  and  309. 

"  In  Fig.  308,  No.  I  is  a  third  molar,  pulp  alive,  with  large 
filling;  No.  2  is  a  porcelain  bridge ;  No.  3  is  a  first  molar, 
pulp  dead,  with  a  metal  bar  entering  the  pulp  cavity. 


252 


OPERATIVE    DENTISTRY. 


"  In  Fig.  309,  No.  I  is  a  second  molar,  pulp  alive,  with  a 
crown  filling  of  gold  or  amalgam  retaining  the  bar  ;  No.  2  is 
a  porcelain  bridge  ;  No.  3  is  a  gold  crown  with  bar  passing 
through  crown  into  root. 

"Fig.  310  is  a  view  of  a  bridge  of  two  teeth — a  central 
porcelain  crown  with  a  lateral  baked  into  it,  the  bar  and  pin 
being  of  the  same  piece,  bent  at  right  angles. 

"  In  Fig.  313,  No.  I  is  a  porcelain  crown  forming  part  of  the 
bridge  ;  No.  '2  is  a  bridged  lateral  with  metal  bar  baked 
through  it ;  No.  3  a  living  cuspid  with  a  metal  bar  running  in 
the  centre  of  a  solid  gold  filling. 

"  Fig.  311  is  a  view  of  a  central  incisor  bridged  on  to  two 
teeth  whose  pulps  have  been  lost. 


Fig.  310. 


Fig.  311. 


Fig.  312. 


"As  many  as  six  teeth  have  been  inserted  in  this  way  on  two 
central  roots,  and  the  posterior  end  of  the  invisible  metal  bar 
running  through  the  six  teeth  worked  firmly  into  a  gold  fill- 
ing in  a  molar — the  six  teeth  being  united  on  their  approxi- 
mal  surfaces  by  the  porcelain  running  between  them  at  the 
baking.  The  backs  of  such  teeth  must  be  given  a  curved 
form  to  insure  a  cleanly  condition. 

"  Fig.  312  is  a  view  of  the  attachment  of  the  bridge  to  a 
tooth  .standing  alone,  where  the  tooth  has  a  gold  crown 
attached,  or  the  bar  is  worked  into  a  filling.  Nos.  i  and  3  are 
teeth  on  a  porcelain  bridge  ;  No.  2,  the  natural  tooth  over 
which  the  bridge  is  saddled. 

"All  teeth  for  this  bridge  work  should  be  ground  so  that  no 


CKYEK  S    IJKIDOE.  253 

considerable  portion  of  ^aiiii  would  be  covered,  the  teeth  just 
touching  the  gum  by  a  point  only  at  the  cervico-labial 
portion."* 

Cryer's  Bridge. — "In  the  mouth  of  a  student  at  the  Phila- 
delphia Dental  College,  where  the  first  right  superior  bicuspid 
was  missing,  and  there  remained  a  portion  of  the  root  of  the 
second  bicuspid  not  strong  enough  to  sustain  a  crown,  and 
likewise  irregular  as  to  position  in  the  arch  (see  Fig.  313),  the 
following  operation  was  performed:  There  was  a  cavity  on  the 
disto-palatine  surface  of  the  cuspid  and  a  mesial  and  crown 
cavity  in  the  first  molar.  The  above  mentioned  root  was 
treated  and  prepared  as  for  filling.  An  impression  of  the  parts 
was  taken   and  casts  made  showin^r  the  articulation  with  the 


N 


lower  teeth.  A  piece  of  slightly  flattened  platinum  wire  was 
fitted  into  the  root  for  a  dowel.  A  small  portion  of  the  cast 
was  trimmed  off,  so  as  to  cause  the  neck  of  the  artificial  crown 
to  bed  into  the  gum.  A  piece  of  thin  platinum  was  burnished 
over  the  root  and  the  vacant  space  corresponding  to  the  origi- 
nal position  of  the  first  and  second  bicuspids,  and  a  hole  made 
through  the  platinum  to  accommodate  the  pin  which  was  to 
be  inserted  into  the  root.  The  pin  was  now  passed  through 
the  plate  into  the  root,  and  treated  as  previously  described  in 
crowning  with  a  plate  tooth.  Two  cuspids  were  selected, 
shaped,  and  backed  with  platinum;  a  piece  of  No.  18  platinum 


*  Cosmos,  xxvm,  583. 


254 


OPERATIVE    DENTISTRY. 


wire,  reaching  from  the  cavity  in  the  cuspid  to  the  cavity  in 
the  molar,  and  passing  close  to  and  back  of  the  artificial 
crowns,  was  attached  to  the  teeth  and  plate  with  wax.  After 
trial  in  the  mouth,  the  appliance  was  invested  and  soldered 
with  pure  gold  over  the  pins,  stays,  and  transverse  wire  (see 
Fig.  313).  In  such  a  case,  before  inserting  the  ends  of  the 
horizontal  wire  into  the  natural  teeth,  it  is  best  to  fill  the  cervi- 

FiG.  314. 


cal  portions  of  the  cavities  with  gold,  after  which  adjust  the 
dowel  in  the  gutta-percha  in  the  root,  as  before  described,  and 
complete  the  operation  by  finishing  the  fillings  in  the  natural 
crowns  (see  Fig.  314).  The  fillings  can  be  temporarily  made 
of  oxychloride  of  zinc  or  gutta-percha,  especially  if  they  are 
large,  and  the  patient  may  be  allowed  to  wear  the  porcelain 
teeth   for   a  few   days,  when,  if  desirable,  the  oxychloride  of 

Fig    315 


zinc  or  gutta-percha  can  be  removed  and  the  cavities  perma- 
nently stopped  with  gold."* 

Melotte's  Bridge. — "Fig.  315  illustrates  a  case  for  the 
supply  of  a  lateral  and  a  bicuspid.  In  this  instance  the  cuspid 
could  be  cut  off,  and  the  root  collared  and  capped  in  combina- 


*  Cosmos,  XXIV.  360. 


M  ELOTTE  S    BR  I  DOE. 


255 


tion  with  a  pin  entering  the  enlarged  pulp  canal  ;  but,  as  there 
may  be  grounds  for  objection  to  cutting  off  sound  teeth,  I 
obviate  the  necessity  by  cutting  a  shoulder  on  the  lingual  por- 
tion of  the  cuspid,  and  suitably  shaping  its  sides  to  permit  a 
close  fitting  of  the  collar  just  under  the  free  margin  of  the 
gum.  A  narrow  strip  of  pure  pattern  tin,  bent  tight  around 
the  tooth  neck,  and  cut  through  with  a  knife  at  the  lap  on  the 
labial  surface,  will  serve  as  a  measure  for  the  length  of  a  strip 
of  22-carat  gold  plate,  No.  29  thick,  and  as  wide  as  the  length 
of  the  distal  side  of  the  cuspid.  The  ends  of  the  gold  are 
then  squared,  and  with  round-nosed  pliers  brought  evenly 
together,  to  be  held  in  flush  contact  by  the  soldering  clamp 
shown  in   Fig.  316.     The  soldered  collar,  with  its  joint  side 

Vie.  316. 


inward,  is  then  adjusted  on  the  tooth  as  accurately  as  possible, 
giving  slight  blows  with  a  mallet  until  the  collar  touches  the 
gum,  when  it  should  be  marked  to  indicate  the  necessary  trim- 
ming to  conform  it  to  the  gum  contour.  After  it  has  been 
thus  trimmed,  the  edges  beveled,  the  labial  part  swelled  with 
contouring  pliers,  and  the  lingual  part  cut  down  to  about  one- 
tenth  of  an  inch  in  width,  the  collar  is  again  driven  on  and 
will  appear  as  seen  in  Fig.  315.  A  stump  corundum  wheel  is 
then  used  to  grind  a  shoulder  on  the  lingual  surface  of  the 
tooth,  grinding  also  the  edges  of  the  collar  flush  with  the 
shoulder.  The  collar  is  again  removed,  and  a  piece  of  thin 
platinum  plate,  about  No.  32,  sufficient  to  cover  the  lingual 


2s6 


OPERATIVE    DENTISTRY. 


surface  of  the  tooth,  is  caught  on  the  Hngual  edge  of  the  collar 
by  the  least  bit  of  solder,  and  all  put  in  place  on  the  cuspid 
(see  Fig.  317).  The  platinum  should  nOw  be  burnished  on  to 
the  shoulder,  and  over  the  tooth  and  collar  to  the  extent  shown 
by  the  lines  in  Fig.  317.  After  trimming  to  those  lines,  and 
careful  replacement  and  burnishing  on  the  tooth,  the  collar 
and  half  cap  are  removed,  filled  with  wet  plaster  and  sand,  and 
the  platinum  soldered  to  the  gold.  It  is  then  placed  on  the 
tooth,  burnished  into  all  the  inequalities  of  the  tooth,  very 
carefully  removed,  invested,  and  enough   solder  flowed  over 


Fig.  317.  Fig.  31 


Fig.  319. 


Fig.  320. 


the  platinum  to  cover  and  give  it  strength.  Fig.  318  shows  it 
complete  on  the  cuspid. 

"  I  have  feared  that  a  detailed  statement  would  imply  a  long 
and  tedious  process,  but  I  have  often  made  such  collars  in  less 
than  an  hour,  and  in  any  case  time  must  be  made  subservient 
to  exactness  of  fit  and  adaptation  to  the  end  in  view. 

"  In  the  preparation  for  fitting  a  collar  on  the  first  molar  (Fig. 
315),  I  should  have  wedged  or  otherwise  separated  it  from  the 
second  molar,  so  that  a  piece  of  sheet  brass  might  be  put  in 
place,  as  shown  by  Fig.  319,  and  an  impression  taken  in 
plaster,  which,  if  allowed  to  get  hard,  would  bring  away  the 


MELOTTES    BRIDGE.  257 

metal.  If  not,  it  could  be  replaced  in  the  ])lastcr.  Melted 
fusible  metal,  when  near  the  coolin^^  point,  is  then  poured  into 
the  impression,  and  when  cold  will  allow  the  safe  removal  of 
both  the  i)laster  and  the  metal  strip.  On  this  metal  model  a 
collar  can  be  formed  that  will  accurately  fit  the  molar,  as  seen 
in  Fig.  315.  If  the  molar  has  no  antagonist,  a  cap  may  at 
once  be  struck  up  on  the  model;  but  if  there  bean  antagonist, 
the  cusps  of  the  natural  molar  should  be  removed  by  grinding 
at  points  where  the  occluding  tooth  will  admit  of  sufficient 
thickness  of  the  gold  cap.  An  e.xact  copy  of  the  ground  cusps 
can  then  be  made  in  less  than  five  minutes,  by  the  use  of  Mol- 
dine  with  its  accessories,  and  the  process  is  as  follows:  Make 
the  tooth  perfectly  dry.  Put  the  collar  on  it.  Nearly  fill  the 
cup  with  Moldine,  and  coat  it  with  soapstone  powder.  Press 
the  compound  on  the  tooth  and  collar  firmly  to  about  one- 
fourth  the  depth  of  the  tooth.  Carefully  remove  the  cup ; 
trim  off  any  overhanging  material,  and  place  the  rubber  ring 
over  the  cup  to  about  one-half  the  depth  of  the  ring.  Melt 
the  fusible  metal  and  pour  it  as  cool  as  it  will  run  from  the 
iron  ladle.  As  soon  as  the  metal  is  hard,  remove  it  from  the 
ring,  taking  care  not  to  impair  the  impression,  which  can  be 
used  again  if  the  die  is  found  imperfect  or  gets  injurec]  in  use. 
Place  the  die  and  ring  in  cold  water,  to  remain  until  quite 
cooled.  While  the  die  is  wet  and  held  over  a  basin  of  water, 
pour  into  the  ring  fusible  metal  which  has  been  stirred  until  it 
begins  to  granulate,  and  quickly  immerse  all  in  the  water.  The 
die  and  counter-die  should  separate  readily  by  tapping  them 
with  a  hammer,  but  if  they  stick,  others  can  be  quickly  made 
from  the  same  impression,  by  the  same  method,  using  more 
care.  With  this  die  and  its  counter-die,  a  piece  of  No.  29  or 
30  gold  plate  is  swaged  to  fit  perfectly  the  cusps  and  collar, 
which,  when  removed,  can  be  held  to  its  place  on  the  cap  by 
the  soldering  clamp,  using  spring  pressure  enough  merel)'  to 
hold  them  together  for  careful  soldering  with  the  pointed  flame 
so  as  not  to  unsolder  the  collar.  The  seamless  collars  are 
excellent  when  care  is  used   in  selecting  the  proper  size,  as 


258  OPERATIVE    DENTISTRY. 

directed  in  the  diagram.  Such  a  bridge  is  shown  completed 
and  in  position  in  Fig.  320."* 

Richmond  Removable  Bridge. — "  Dr.  C.  M.  Richmond, 
in  making  removable  dentures  of  the  entirely  soldered  kind, 
employs  a  zinc  die  made  from  a  cast  of  the  anchor  tooth  with 
its  cap  on.  He  makes  of  crown  metal  (platinum  faced  with 
gold)  a  collar  somewhat  smaller  than  the  tooth  cap,  and  deep 
enough  to  reach  from  the  gum  to  about  a  sixteenth  of  an  inch 
above  the  cap.  He  then  drives  the  die  into  the  collar  so  far 
that  the  extra  sixteenth  of  an  inch  can  be  hammered  over  and 
burnished  down  on  the  die  end  to  form  a  flanged  collar.  Out- 
side of  this,  in  the  same  manner,  he  forms  another  flanged 
collar  and  then  solders  the  two  together,  thus  obtaining  a 
close  fitting,  stiff  collar  that  will  not  stretch  in  being  tele- 
scoped on  and  off  the  anchorage,  and  is  kept  by  the  flange 
from  being  forced  too  far  over  the  tooth  cap. 

"  It  may  be  well  to  add  that  in  the  use  of  an  impression-cup 
for  holding  the  plaster  and  sand  around  the  parts  to  be  subse- 
quently removed  from  the  mouth,  the  inside  of  the  cup  should 
first  be  slightly  oiled,  to  allow  a  separation  of  the  cup  when 
the  mass  is  being  prepared  for  the  soldering,"t 

Starr's  Removable  Bridge. — "Apiece  of  thin  platinum 
plate.  No.  36  gauge,  a  little  wider  than  the  space  to  be  covered 
with  the  teeth,  is  fitted  and  burnished  over  the  space  between 
the  abutment  teeth  which  have  been  so  trimmed  that  the  caps 
described  will  .slide  on  and  off  easily.  These  caps  are  now 
cemented  to  the  platinum  plate  and  collars  made  and  fitted  to 
properly  fill  the  space  between  the  abutment  teeth.  They  are 
held  in  contact  with  each  other  and  with  the  platinum  plate 
by  running  melted  white  wax  in  between  them.  The  whole 
piece  may  then  be  transferred  from  the  model  to  the  mouth, 
and  stiff-mi.xed  plaster  and  sand  pressed  into  and  over  the 
collars  and  caps. 

"  When    the    plaster  has  set,   the  mass  may    be    removed, 

*  Cosmos,  xxvin,  746.  f  "  Am.  Syst.  Dent.,"  n,  890. 


STAKK  S    KKMOVAIII.E    UKIIKa-:. 


259 


tiiinincd,  and  the  wax  melted  away,  with  the  result  shown  in 
Fi^.  321.  The  Hnes  of  contact  of  the  coUars  with  each  other, 
with  the  caps  and  vvitli  the  plate  are  to  be  neatly  soldered, 
when  the  investment  may  be  removed,  leaving  the  bridge  as 
shown  by  Fig.  322.  The  free  edges  of  the  plate  may  then  be 
trimmed  to  the  margins  of  the  collars  or  caps,  and  the  whole 


Kk;.  321. 


Fig.  322. 


Fig.  323. 


denture  polished.  The  bridge  may  now  be  slipped  on  and  off 
the  natural  abutment  teeth  with  just  enough  of  friction  to 
retain  the  denture  in  position,  and  yet  allow  of  its  ready 
removal. 

"Suitable  cusp  crowns  (see  Fig.  323)  are  now  selected,  the 
caps  partly  filled  with  wax,  and  the  cusps  placed 
in  position.  The  denture  is  then  tried  in  the  mouth 
and  the  proper  occlusion  obtained  by  grinding  or 
filling  the  edges  of  the  caps.  The  piece  is  now  to 
be  thoroughly  cleansed  and  dried  ;  the  cups  nearly 
filled  with  insoluble  cement  or  hot  gutta ;  the  cusp 
crowns  set  in  the  cups ;  the  bridge  put  quickly  in  place,  and 
the  patient  directed  to  firmly  and  repeatedly  close  the  jaws,  to 
properly  determine  the  occlusion.  It  will  be  found  best  to 
place  a  piece  of  paper,  the  thickness  of  a  postal  card,  over 
the  porcelain  cusps  when  forcing  the  denture  to  place,  so  as 
to  ensure  that  they  shall  be  a  little  short,  and  thus  avoid  irri- 
tation of  the  anchorage  teeth  in  mastication.  These  anchor- 
age teeth  or  roots  will  in  time  elongate  and  form  a  close 
occlusion.  When  the  cement  is  properly  hardened  the  piece 
mav  be  removed.     A  hole  should  now  be  drilled  through  the 


26o 


OPERATIVE    DENTISTRY. 


metal  cups,  to  allow  escape  of  surplus  filling  material.  A 
small  quantity  of  gutta-percha  thoroughly  warmed  should 
now  be  placed  in  the  caps,  and  with  a  piece  of  card  placed 
between  them  and  the  occluding  teeth,  the  caps  should  be 
forced  home.     The  completed  case  is  represented  in  Fig.  324. 


Fig.  324. 


,,,|||P1IP"'^T««^'!™^ 


"  The  bridge  may  at  any  time  be  removed  with  warmed 
forcep  beaks  held  long  enough  on  the  caps  to  soften  the 
gutta-percha.  The  cusp  crowns  may  be  removed,  if  desired, 
by  the  same  method  and  replaced  without  detaching  the 
bridge. 

Fic 


"  A  modified  bridge  is  shown  in  Fig.  325.  It  will  be  observed 
that  collars  have  been  firmly  fixed  with  cement  or  gutta-percha 
on  the  abutments  which  have  their  occluding  surfaces  ground 
flat  on  their  inner  aspects,  so  that  the  partial  cap  shown  may 


STAKKS    KKMOVAHM':    IU<II)(;K. 


261 


thus  prevent  the  telescoping  collars  from  bein<^  forced  too  far 
down  on  the  teeth.  By  means  of  a  frame-saw  a  narrow 
tongue  is  cut  on  the  outer  surface  of  each  telescoping  collar, 
the  free  portion  serving  as  a  spring  clasp  to  hold  the  bridge 
securely  on  the  abutment  teeth,  and  still  allow  the  removal  of 

Fig.  326. 


the  piece  when  so  desired.  T'ig.  326  shows  such  a  bridge  in 
place.  It  is  obvious  that  if  in  this  instance  rhe  roots  only  of 
the  cuspid  and  second  molar  had  been  present,  they  could,  by 
means  of  the  collar  and  cusp-crown  devices,  have  been  put  in 
shape  to  serve  as  abutment  teeth  for  the  telescoping  bridge 
shown  in  Figs.  325  and  326. 


Fig.  327. 


Fk;.  32 


"The  second  molar  roots  so  crowned  are  seen  in  Fig.  327. 
When  it  is  desirable  to  show  the  faces  of  the  porcelains  to  a 
greater  degree,  the  collars  maj'  be  cut  away  on  the  buccal 
sides  and  countersunk  crowns  be  used,  as  illustrated  by 
Fig.  328. 


262  OPERATIVE    DENTISTRY. 

"  The  platinum  base  may  either  rest  broadly  on  the  gums  or 
be  sloped  so  that  only  the  buccal  border  shall  touch  the  gums, 
or  it  may  be  so  shaped  as  to  be  entirely  free  from  the  gum. 
This  is  done  by  building  upon  the  plaster  cast  and  bending  the 
platinum  plate,  and  shaping  the  gold  tubes  to  the  surface  so 
made,  depending  wholly  for  support  on  the  abutment  teeth  or 
roots. 

"  Briefly  stated,  the  points  of  excellence  in  this  bridge  are 
strength,  lightness,  avoidance  of  liability  to  breakage  of  the 
porcelain  in  soldering,  ease  of  construction  and  adaptation,  and 
the  facility  with  which  it  maybe  reorganized,  or  for  any  reason 
be  removed  and  replaced.  This  last  feature  is  of  special  value 
in  the  not  infrequent  event  of  subsequent  alveolar  abscess,  for 
in  cases  such  as  are  shown  in  Fig.  326,  the  bridge  may  be 
removed,  the  involved  teeth  drilled,  medicaments  applied,  the 
bridge  replaced,  and  this  process  repeated  without  depriving 
the  patient  of  the  use  of  the  denture."* 

Repairing  Crown  and  Bridge  Work. — It  is  quite  prac- 
ticable to  remove  crowns  and  bridges  for  purposes  of  repair, 
and  to  replace  them. 

Any  crown  with  soldered  backing  mounted  on  a  metal  post 
and  set  with  cement  may  be  readily  removed  by  drilling  a  hole 
through  the  backing  in  the  direction  of  the  post,  using  first  a 
small  round  bur,  No.  5  or  6,  and  afterward  one  considerably 
larger  than  the  post,  No.  9  or  10.  This  will  usually  cut  out 
the  cap  clear  of  the  post  at  once.  If  the  post  be  a  little  out 
of  line  of  the  hole  the  latter  will  be  large  enough  to  enable 
the  operator  to  see  in  what  direction  to  cut  laterally  to  effect 
the  purpose.  If  the  crown  has  a  band  and  does  not  come  off 
readily  after  the  post  is  separated,  take  a  small  round  bur.  No. 
I  or  o,  and  cut  the  band  across,  when  it  may  be  opened  a  little 
and  the  cement  loosened.  With  a  very  fine  bur.  No.  00  or 
000,  drill  out  the  cement  from  the  lingual  side  of  the  post, 
when  it  may  be  removed,  leaving  the  root  uninjured.     Bend 


*  Cosmos,  XXV in,  209. 


Ki;i'AIl<IN(;    CKOWN    AND    HKIIXIK    WORK.  263 

tlic  bantl  to  place  and  put  a  new  post  in  position,  hold  it  with 
wax  cement,  invest,  fill  around  the  post  with  ^old  plate  or  foil, 
put  a  bit  of  ^old  plate  in  the  band  where  it  was  cut,  solder 
and  finish. 

To  remove  a  cap,  cut  with  a  fine  bur  across  the  band  and 
part  way  across  the  <^rindin^  surface  if  need  be,  and  open  it 
sufficiently  to  loosen  it.  Cleanse,  refit,  invest,  place  gold  in  the 
slot,  solder  and  finish. 

An  open  band  may  be  removed  in  the  same  manner. 

In  a  case  of  an  all-porcelain  crown,  destruction  of  the 
crown  seems  to  be  the  only  way  of  removing. 

If  a  porcelain  is  broken  from  a  bridge  crown,  it  may  be 
replaced  without  removing  the  bridge. 

The  projecting  pins  are  cut  off,  and  two  holes  drilled  through 
the  backing  in  the  exact  position  occupied  by  the  pins.  The 
narrow  space  of  metal  now  intervening  between  these  two  holes 
is  cut  out  with  a  fissure-bur.  This  leaves  a  groove  which 
should  not  be  wider  than  the  diameter  of  the  pins.  The  length 
of  this  groove  should  now  be  increased  on  the  lingual  surface, 
but  not  on  the  front.  The  object  of  this  is  to  give  a  dovetail 
shape  to  the  groove,  which  is  easily  effected  by  the  use  of  the 
same  fissure-bur  above  referred  to.  The  lingual  appearance 
of  this  groove  when  properly  shaped  is  shown  in  Fig.  329. 
The  proper  tooth  is  selected,  the 
pins  passed  through  this  hole  and  ^"-  ^^^ 

bent  outward  into  the  dovetail 
groove.  It  will  be  found  almost 
impossible  to  bend  these  pins  into 
their  proper  positions  by  any  ordi- 
nary means,  so  as  to  hold  the  tooth  quite  rigid  and  immovable. 
An  instrument  herewith  illustrated  (Fig.  330)  accomplishes  this 
feature  of  the  work  in  a  very  simple  and  effective  manner. 
Its  use  is  almost  too  evident  to  require  description.  Both 
the  rubber  pad  which  rests  upon  the  porcelain  front  and  the 
wedge-shaped  point  which  passes  between  the  pins  are  made 
to  rotate  in  their  sockets,  so  that  any  desired  position  can  be 


264 


OPERATIVE    DENTISTRY. 


obtained.  A  firm  closure  of  the  instrument  when  in  position 
forces  the  pins  outward  into  the  dovetail  groove,  and  the 
tooth  is  immovably  fixed  in  place.  It  now  remains  but  to  fill 
the  space  between  the  pins  with  any  form  of  cohesive  gold  (I 


Fig. 


use  crystal  gold),  and  with  corundum,  Arkansas,  and  rubber 
points  in  the  engine  the  surface  is  finished  and  polished.  The 
wedge-shaped  filling  of  gold  acts  as  a  keystone  between  the 
pins  and  makes  a  most  perfect  method  of  repair. 


*  Cosmos,  xxvn,  713. 


APPENDIX 


The  following  arc  formuht  for  some  of  the  best  alloys  for 
amalgams : — 

Townsend's:  Silver, 45.5 

Tin, 54.5 

1 00.0 

A  softer  alloy  is  made  as  follows : — 

Silver, 40  Silver, 30 

Tin, 60  or.  Tin, 60 

Gold 6 

100  Zinc, 4 

ICX) 

Alloy  for  a  hard,  quick-setting  amalgam  : — 

Silver, 60 

Tin, ....  35 

Copper,       5 

100 

For  a  gold  alloy: — 

Silver, 42 

Tin 54 

Gold, 4 

100 

For  a  copper  alloy  : — 

Silver, 31.5 

Tin, 62.5 

Copper, 6 


18 


265 


26.6  OPERATIVE    DENTISTRY. 

The  following  have  also  proved  good  : — 


Silver, 57 

Tin, 39 

Copper, 3 

Gold, I 


Silver 44 

Tin, 51.5 

Zinc 3.5 

Platinum,      ....     I 


Silver, 35 

Tin, 60 

Gold, 2.5 

Platinum, 2.5 


Silver, 39 

Tin, 59 

Gold I 

Platinum, i 


Silver, 53 

Tin, 38 

Copper, 8 

Platinum, i 


Silver,    ......  39 

Tin,    .    : 58 

Gold,      2.5 

Platinum, .5 


Silver, 42 

Tin, 51 

Gold, 4 

Copper, 3 


Silver 47.5 

Tin, 47-5 

Copper, 5 


Richmond's  solder  for  gold  coin  plate  : — 

Fine  brass  wire, »    .  i  part 

Gold  coin, 4  parts.-* 


Melotte's  metal : — 

Tin 5  parts 

Lead, 3  parts 

Bismuth, 8  parts.* 


Melotte's  Moldine  is  composed  of  potters'  clay  and  glycer- 


me. 


*  Evans'  "  Crown  and  Bridge  Work." 


APPENDIX.  267 

REFERENCE    LIST   OF    MEDICAMENTS    USED   IN 

OPERATIVE  DENTISTRY. 
Alcohol : — A  general  stimulant  and  a  solvent. 
Alum: — Astringent  and  styptic. 
Atiiyl  Nitrite  : — An  antidote  to  chloroform  narcosis. 
Arscnio7is  Acid : — Used  for  devitalization  of  the  dental  pulp. 

Apply  one-fiftieth  of  a  grain. 
Bicarbonate  of  Soda  : — Antacid.  ^ 

Bichloride  of  Mercury : — Germicide.     Used  in   solution,   i   to 

1000. 
Calendula : — A    soothing  application   to   irritated    pulps,    or 

wounds  of  the  mouth. 
Capsicum : — Useful  in  pericementitis. 
Carbolic  Acid : — Antiseptic  and  local  anaesthetic.     Applied  as 

an  obtundent   to  sensitive   dentine ;  to   relieve    odontalgia 

from  exposed  pulp,  and  in  treatment  of  alveolar  abscess.  Oil 

of  clove  will  mask  its  taste  and  odor  to  some  extent. 
Carvacrol : — May  be  used  as  a  substitute    for  creasote  and 

carbolic  acid. 
Chloroform  : — Anaesthetic,  and  obtundent  of  sensitive  dentine. 
Cocaine  : — A  local  anaesthetic,  and  obtundent. 
Creasote: — Stimulant,  sedative   and  antiseptic.     Its  principal 

use  is  in  inflammation  of  the  pulp. 

Eucalyptus  Oil : — Antiseptic,  disinfectant,  and  sedative.  Used 
in  treatment  of  teeth  with  putrescent  pulps,  and  in  alveolar 
abscess. 

Glycerole  of  Thymol : — Antiseptic.  Useful  in  treatment  of  sup- 
purating pulps,  and  as  a  dressing  in  ulcers  and  wounds  of 
the  mouth. 

Gutta-percha  : — Combined  with  mineral  substances,  it  is  used 
as  a  plastic  material  for  filling  teeth,  and  dissolved  in  chloro- 
form, as  a  capping  for  exposed  pulps. 

Hydro7iapht]iol : — A  non-irritant  antiseptic,  and  disinfectant. 


268  OPERATIVE    DENTISTRY. 

Iodine: — Stimulant  and  sorbefacient.  Used  locally  in  peri- 
cementitis, and  inflammations  of  the  mouth. 

Iodoform  : — Antiseptic,  stimulant,  anodyne  and  disinfectant. 
Used  in  combination  with  eucalyptus  oil,  or  with  equal 
parts  eucalyptus  oil  and  oil  of  cloves,  as  an  application  to 
inflamed  pulps,  and  also  as  a  dressing  after  removal  of 
putrescent  pulps,  and  for  relief  of  pain  following  extraction 
of  teeth  affected  with  pericementitis. 

lodol : — Propertfbs  similar  and  uses  the  same  as  iodoform.  It 
is  somewhat  questionable  if  it  is  as  effective  as  the  latter. 

laharraque' s  Solution  : — A  disinfectant  and  deodorizer. 

McntJiol : — An  obtunder  of  sensitive  dentine. 

Mercury : — An  ingredient  of  amalgams. 

Morplda,  Acetate  or  iSidphate  : — An  ingredient  of  nerve  paste. 

Myrrh : — Stimulant  and  astringent.  Used  as  an  application 
to  inflamed,  ulcerated  and  spongy  gums. 

Nitric  Acid : — Caustic.  Used  for  cancrum  oris  and  malignant 
ulcers. 

Oil  of  Cafeput : — A  solvent  for  gutta-percha. 

Oil  of  Clove  : — An  aromatic  stimulant.  Used  as  an  applica- 
tion to  irritated  and  painful  pulps.  A  substitute  for  creasote 
and  carbolic  acid.  Used  also  in  combination  with  creasote 
and  carbolic  acid  to  render  them  more  pleasant. 

Orris  Root : — An  ingredient  of  dentifrices. 

Permanganate  of  Potassium  : — A  disinfectant  and  deodorizer. 
Useful  in  root  canals  and  in  the  treatment  of  fetid  and  gan- 
grenous ulcerations  of  the  mouth,  Riggs'  disease  and 
offensive  breath, 

Persulp/iate  of  Iron  : — A  styptic  for  arrest  of  hemorrhage  after 
extraction. 

Phenol  Sodique  : — Astringent  and  styptic.  Used  to  arrest  hem- 
orrhage and  to  relieve  soreness  after  extraction.  May  be 
applied  in  full  strength  on  cotton,  or  diluted  with  water  as 
a  wash. 


AFPENDIX.  269 

Pliosplioric  Acid : — An  obtundcr  of  sensitive  dentine,  and  an 
essential  component  of  cements  for  filling  teeth. 

Prepared  Chalk: — Antacid.  Employed  principally  in  tooth 
powders. 

Resorcin : — A  non-irritant  antiseptic  and  disinfectant. 

Salicylic  Acid : — Useful  in  treatment  of  ^an<^renous  pulps,  and 
in  inflammations  of  the  mucous  membrane  and  <^ums. 

Sa/idarac : — Used,  dissolved  in  alcohol,  to  saturate  cotton  for 
use  as  temporary  stopping. 

Silver  Nitrate  : — Astringent  and  styptic. 

SidpJinric  Acid,  Dilute  or  Aromatic : — For  inflamed  gums  and 
for  dissolving  salivary  calculus. 

Sulphuric  Ether : — General  anzesthetic. 

Tainiic  Acid : — An  astringent  and  styptic.  Useful  in  inflam- 
mations, and  as  an  obtunder  of  sensitive  dentine. 

Tcrebcn : — A  non-irritant  antiseptic  and  disinfectant. 

Zinc  Chloride : — Astringent,  antiseptic  and  disinfectant,  and  a 
powerful  cscharotic.  Employed  as  an  obtunder  of  sensitive 
dentine,  and  as  an  injection  in  chronic  alveolar  abscess,  ten 
to  eighty  grains  to  the  ounce  of  water. 

Zinc  Oxide : — Used  in  combination  with  zinc  chloride  to  form 
a  cement  filling  material. 

Zi)ic  Sulphate  :-, — A  mild  astringent ;  useful  in  inflammations. 


INDEX. 


Abrasion,  90. 

Abscess,  alveolar,  in. 

Accidents  in  extraction  of  teeth,  118. 

Alloys  for  amalgam,  265,  266. 

Alveolar  processes,  9. 

Amalgam,  84. 

alloys  for,  265,  266, 

mixing,  85. 

packing,  86. 

properties  of,  84. 
Anresthesia,  142. 

conditions  unfavorable  to,  146. 

local,  147. 

stages  of,  142. 

unfavorable  symptoms,  147. 
Anaesthetics,    physiological    action    of, 

142. 
Anchorages,  or  abutments    for  bridge- 
work,  221. 

bar,  222. 

open  cap,  221. 
Annealing  gold,  76. 
Articulation  of  the  teeth,  9. 
Automatic  mallet,  81. 


Bleaching  teeth,  loi. 
Bridge- work,  221. 

adjusting,  227,  235,   240,  241, 

245- 
anchorages  for,  221. 
bar  anchorage,  222. 
Brown's,  250. 
connecting  bands  for,  223. 
crowns  for,  224,  226,  229,  243. 
Cryer's,  253. 
Low's,  241. 
Melolte's,  254. 
open  cap  for,  221. 
repairing,  262. 
Richmond's  removable,  258. 
soldering,  232. 
Starr's  removable,  258. 
Burnishers,  42. 


Calculus,  salivary,  52. 
Cap,  open,  221. 

with  pure  gold  edge,  222. 
Caries,  dental,  24. 
Cavities,  formation  of  for  filling,  60. 

opening,  59. 

removal  of  decay  from,  60. 
Cements,  87. 
Cementum,  12. 
Chloroform,  146. 
Clamps,  38. 

forceps  for,  41. 

Freeman's  cervix,  42. 
Cleanliness,  46. 
Cleansing  teeth,  54. 
Combination  fillings,  88. 
Connecting  bands  for  bridge- work,  222. 
Corundum  disks,  45. 
Crowns,  Baldwin's,  199. 

Bonwill's,  190. 

Brown's,  181. 

for  bridge-work,  224,  226,  229. 

gold  cap,  158. 

How's,  193. 

Kirk's,  214. 

Leech's,  216. 

Logan's,  177. 

Low's,  201. 

mandrel  system,  166. 

Mattison's,  211. 

Meriam's,  207. 

repairing,  262. 

Richmond's,  155. 

improved,  206. 

Stowell's,  217. 
Crown  work,  149. 

instruments   and   materials   for, 
149. 

preparing  roots  for,  154. 


Decay,  dental,  24. 
Deciduous  teeth,  23. 
Dental  caries,  24. 


271 


2/2 


INDEX. 


Dental  matrix,  76. 

pulp,  94. 

tissues,  II. 
Dentine,  11. 

secondary,  92. 

sensitive,  91. 
Dentition,  12. 

periods  of,  13. 
Dentist,  personal  appearance  and  habits 

of,  46. 
Deposits  on  the  teeth,  52. 
Diagram  of  teeth,  51. 
Die  metals,  152,  153. 
Disinfectants,  46. 
Disk  carrier,  45. 
Disks  for  engine,  45. 
Dislocation  of  jaw,  119. 
Drills,  32. 


Electric  mallet,  81. 
Elevator  for  extraction,  139. 
Enamel,  11. 
Engine,  dental,  43. 

equipments  for,  44,  45. 
Engine  mallet,  81. 
Erosion,  90. 
Eruption  of  teeth,  13. 
Ether,  145. 

Examination  of  mouth,  50. 
Excavators,  30. 

Head's,  32. 
Exclusion  of  moisture,  62. 
Exostosis,  see  hypercementosis. 
Extraction  of  teeth,  116. 

accidents  in,  118. 

elevator  for,  139. 

indications  for,  117. 

instruments  for,  121. 

key  for,  139. 

roots,  135. 

First  molars,  102. 
Forceps,  121. 

English,  136. 

Gangrene  of  socket,  120. 
Gold,  annealing,  76. 

cohesive,  74. 

crystal,  75. 
•  for  filling,  68. 

non-cohesive,  74. 

preparation  of,  68. 

rolled,  73. 
Gutta-percha,  86. 


Hand  mallet,  80. 

Hard  bits,  32. 

Hemorrhage  after  extraction,  119. 

treatment  of,  120. 
Holding  instruments,  47. 
Hot-air  syringe,  91. 
Hypercementosis,  106. 


Instruments,  broaches,  33. 

burnishers,  42. 

burs,  33. 

drills,  32. 

excavators,  30,  31. 
heads,  32. 

for  amalgam,  36. 

for  cement,  36. 

for  crown  work,  149. 

for  examination,  50. 

for  extraction,  121. 

for  filling,  36. 

for  finishing  fillings,  43. 

hard  bits,  32. 

holding,  47. 

making,  27. 

pluggers  for  gold,  37,  74. 

root- canal  drills,  34. 

scalers,  35. 

sharpening,  28. 
Investment  material,  152. 


Key  for  extracting,  139. 


Mallet,  79. 

automatic,  81. 

electric,  81. 

engine,  81. 

hand,  80. 
Mandrels  for  engine,  44. 
Matrices,  76. 
Medicaments,  267. 
Moisture,  exclusion  of,  62. 
Mouth,  examination  of,  50. 


Necrosis  of  teeth,  no. 
Nitrous  oxide  gas,  143. 


Obtundents,  91,  92. 
Occlusion  of  the  teeth,  10. 
Opening  cavities,  59. 
Oxychloride  of  zinc,  87. 
Oxyphosphate  of  zinc,  87. 


INDEX. 


273 


Pericementitis,  106. 

phagedenic,  107. 
Pericementum,  12. 
Personnel  oi  the  lieiuist,  46. 
Phagedenic  pericementitis,  107. 
Plastic  fillings,  84. 
Pluggersfor  gold,  37,  74. 
Preparation  of  cavities  for  filling,  60. 

of  gold,  68. 

of  roots  for  filling,  99. 
Porcelain  disk  fillings,  89. 
Pulp,  dental,  94. 

congestion  and  inflammation  of, 

95- 
devitalization  of,  96. 
diseases  of,  95. 
exposed,  94. 
irritation  of,  95. 
partially  exposed,  94. 
removal  of;  97,  98. 
sensitive,  94. 
Pyorrhcea  alveolaris,  107. 


Rapid  breathing,  147. 

Repairing  crown-  and  bridge-work,  262. 

Riggs'  disease,  107. 

Root-canal  pliers,  100. 

Roots,  filling,  100. 

preparation  of,  for  filling,  99. 
Rubber  dam,  application  of,  62. 

holder  for,  63,  64,  65. 


Salivary  calculus,  52. 
Scalers,  35,  54. 
Secondary  dentine,  92. 
Sensitive  dentine,  91. 
Separatmg  teeth,  56. 


Separators,  56,  58. 

Solder,  154. 

Soldering  bridge-work,  232. 

Stain  on  teeth,  53. 

Steel,  working,  27. 

Syncope,  1 19. 


Teeth,  anatomical  divisions  of,  14. 

articulation  of,  9. 

bleaching,  loi. 

classes  of,  14. 

decay  of,  24. 

deciduous,  description  of,  23. 
treatment  of,  104. 

eruption  of,  13. 

extraction  of,  1 16. 

implantation  of,  ill. 

necrosis  of,  1 10. 

occlusion  of,   10. 

of  lower  jaw,  20. 

of  upper  jaw,  15. 

permanent,  description  of,  15, 

replantation  of,  iio. 

surfaces  of,  15. 

transplantation  of,  1 10. 
Third  molars,  104. 


Universal  forceps,  Brewer's,  42. 


Wedging,  58, 

Wheel-bur,  191. 

Wire  for  instruments,  29. 


Zinc,  oxychloride  of,  87. 
"     oxyphosphate  of,  87. 


'9 


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character,  receive  full  attention. 

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"  Fagge  was,  to  my  mind,  the  type  of  true  medical  greatness.  I  believe  he  was  capable  of  any  kind  of 
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but  he  found  new  facts.  Fortner  volumes  of  Guy's  Hospital  Reports  contain  ample  and  most  valuable  proof  of 
his  greatness  as  a  physician.  His  power  of  observation  was  sustained  by  immense  memory,  and  brought  into 
action  by  vivid  and  constant  suggestiveness  of  intelligence.  He  was  a  physician  by  grace  of  nature,  and  being 
gifted  with  a  quickness  of  perception,  a  genius  for  clinical  facts  and  a  patience  in  observation,  he  was  at  once 
recognized  as  a  successful  practitioner  and  a  leading  figure  in  the  hospital  and  among  the  profession. 


Press  Notices  of  Fagge's  Practice. 

"Tliose  wlio  have  read  Guy's  Hospital  Reports  for  tlie  past  twoity  years  and  tlie  many 
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to  find  reference  made  to  a  dozen  authors  of  different  nationalities.  His  memory  must  have 
been  marvelous,  and  he  was  an  original  worker  and  thinker.  *  *  *  Inflammation — that 
prolific  subject  for  medical  and  surgical  text-book  writers — is  very  fully  and  clearly  discussed, 
and  in  such  charming  style  as  to  make  it  very  interesting.  Tubercle  receives  much  considera- 
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ALLIN6HAM.  Diseases  of  the  Rectum.  Fistula,  Haemorrhoids,  Painful  Ulcer, 
Stricture,  Prolapsus,  and  other  Diseases  of  the  Rectum,  their  Diagnosis  and 
Treatment.  By  William  Allingham,  f.r.c.s.  Fourth  Edition,  Enlarged. 
Illustrated.     Svo.  Paper  covers,  .75;  Cloth,  $1,25 

ALTHAUS.  Medical  Electricity.  Theoretical  and  Practical.  Its  Use  in  the  Treat- 
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Third  Edition,  Enlarged.    246  Illustrations.     Svo.  Cloth,  $6.00 

ANDERSON.  A  Treatise  on  Skin  Diseases.  With  special  reference  to  Diagnosis 
and  Treatment,  and  including  an  Analysis  of  ir,ooo  consecutive  cases.  By  T. 
McCall  Anderson,  m.d..  Professor  of  Clinical  Medicine,  University  of  Glasgow. 
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ARLT.  Diseases  of  the  Eye.  Clinical  Studies  on  Diseases  of  the  Eye.  Including  the 
Conjunctiva,  Cornea  and  Sclerotic,  Iris  and  Ciliary  Body.  By  Dr.  Ferd.  Ritter 
VON  Arlt,  University  of  Vienna.  Authorized  Translation  by  Lyman  Ware, 
m.d..  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  Chicago. 
Illustrated.     Svo.  Cloth,  $2.50 

BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Methods  Applied  to 
Obstetric  Practice.  By  Dr.  Paul  Bar,  Obstetrician  to,  formerly  Interne  in,  the 
Maternity  Hospital,  Paris.  Authorized  Translation  by  Henry  D.  Fry,  m.d., 
with  an  Appendix  by  the  author.     Octavo.  Cloth,  1.75 


«  p.  BLAKISTON,  SON  &'  COJS 

BARNES.  Lectures  on  Obstetric  Operations,  including^  the  Treatment  of  Hemor- 
rhage, and  forming  a  Guide  to  Difficult  Labor.  By  Robert  Barnes,  m.d., 
F.R.C.P.     Fourth  Edition.     Illustrated.     8vo.  Cloth,  I3.75 

SAE.KETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
and  Dentistry.  Extraction  of  Teeth,  etc.  By  A.  W.  Barrett,  m.d.  Illustrated. 
Practical  Series.     \_See  page  igT^  Cloth,  ;gi. 00 

BARTLEY.  Medical  Chemistry.  A  Text-book  for  Medical  and  Pharmaceutical 
Students.  By  E.  H.  Bartley,  m.d..  Professor  of  Chemistry  and  Toxicology  at  the 
Long  Island  College  Hospital;  President  of  the  American  Society  of  Public 
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BEALE.    On  Slight  Ailments ;  their  Nature  and  Treatment.    By  Lionel  S.  Beale, 

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Edition.     Enlarged  and  Illustrated.  Paper  covers,  .75  ;  Cloth,  $1.25 

Urinary  and  Renal  Diseases  and  Calculous  Disorders.    Hints  on  Diagnosis 

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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS. 


BIBLE  HYGIEKE ;  or  Health  Hints.  By  a  physician.  Written  to  impart  in  a 
popul.'ir  and  condensed  form  the  elements  of  Hyfjiene;  showinj^  how  varied  and 
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Medica  in  Jefferson  Medical  College,  Philadelphia.  The  Eleventli  Edition,  thor- 
oughly revised,  and  in  many  parts  rewritten,  by  his  son,  Clement  Bioule,  m.d.. 
Assistant  Surgeon,  U.  S.  Navy,  and  Henky  Morris,  m.d.,  Demonstrator  of 
Obstetrics  in  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  of 
Philadelphia,  etc.  The  Botanical  portions  have  been  curtailed  or  left  out,  and 
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BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
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Laboratory  Teaching.  Progressive  Exercises  in  Practical  Chemistry.  In- 
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BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  icx?  Illustrations. 
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BRUBAKER.  Physiology.  A  Compend  of  Physiology,  specially  adapted  for  the 
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Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
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trated,    No.  4,? Quiz- Compend  Series?     i2mo.  Cloth,  $1.00 

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Fourth  Edition,  much  enlarged,  with  twelve  lithographic  and  numerous  other 
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BTJLKLEY.  The  Skin  in  Health  and  Disease.  By  L.  Duncan  Bulkley,  m.d.. 
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BUXTON.  On  Anaesthetics.  A  Manual.  By  Dudley  Wilmot  Buxton,  m.r.c.s., 
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BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d.,  Prof, 
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p.  BLAKISTON,  SON  &*  CO.'S 


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BYFORD.  Diseases  of  Women.  The  Practice  of  Medicine  and  Surgery,  as 
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A.M.,  M.D.,  Professor  of  Gynaecology  in  Rush  Medical  College  and  of  Obstetrics 
in  the  Woman's  Medical  College  ;  Surgeon  to  the  Woman's  Hospital ;  Ex-Presi- 
dent American  Gynaecological  Society,  etc.,  and  Henry  T.  Byford,  m.d.,  Sur- 
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■  pital ;  President  Chicago  Gynaecological  Society,  etc.  Fourth  Edition.  Revised, 
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CARTER.  Eyesight,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation 
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CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,  by  Munde.  Eighth 
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Illustrations.  The  Theory  and  Practice  of  Obstetrics  ;  including  the  Diseases 
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Member  of  the  Imperial  Academy  of  Medicine,  Adjunct  Professor  in  the  Faculty 
of  Medicine  in  Paris.  Remodeled  and  rearranged,  with  revisions  and  additions, 
by  S.  Tarnier,  m.d..  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Faculty  of  Medicine  of  Paris.  Eighth  American,  from  the 
Eighth  French  and  First  Italian  Edition.  Edited  and  Enlarged  by  Robert 
J.  Hess,  m.d.,  Physician  to  the  Northern  Dispensary,  Phila.,  etc.,  with  an  Ap- 
pendix by  Paul  F.  Mund6,  m.d.,  Professor  of  Gynaecology  at  the  New  York 
Polyclinic,  and  at  Dartmouth  College  ;  Vice-President  American  Gynaecological 
Society,  etc.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and  other  Full- 
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gravings.    Students'  Edition.     One  Volume,  octavo. 

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COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
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COOPER  on  Syphilis  and  Pseudo-Syphilis.  By  Alfred  Cooper,  f.r.c.s..  Sur- 
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COLLIE,  On  Fevers.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology, 
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Hospital.    With  Colored  riates.    I^aclical  Series.     See  Page  ig.  Cloth,  ;J2. 50 

CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis  and 
Treatment.     With  llhistrations.  Cloth,  J5.50 

CULLINGWORTH.    A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

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A  Manual  for  Monthly  Nurses.    Third  Edition.    32mo.  Cloth,  .50 

DAVIS.  Biology.  An  Elementary  Treatise.  IJy  J.  R.  Ainsworth  Davis,  of 
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DAT.     Diseases  of  Children.    A  Practical  and  Systematic  Treatise  for  Practitioners 

and  Students.     By  Wm.  H.  Day,  m.d.     Second  Edition.     Rewritten  and  very 

much  Enlarged.     8vo.     752  pp.     Price  reduced.  Cloth,  $3.00;  Sheep,  $4.00 

On  Headaches.     The  Nature,  Causes  and  Treatment  of  Headaches.     Fourth 

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DILLNBEROER.  On  "Women  and  Children.  The  Treatment  of  the  Diseases  Pecu- 
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DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
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DORAN.  Gjrnaecological  Operations.  A  Handbook.  By  Alban  Doran,  f.r.c.s., 
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DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
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DURKEE,  On  Gonorrhoea  and  Syphilis.  By  Silas  Durkee,  m.d.  Sixth  Edition. 
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FIELD.    Evacuant  Medication — Cathartics  and  Emetics.    By  Henry  M.  Field, 
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ber Gynaecological  Society  of  Boston,  etc.     i2mo.     288  pp.  Cloth,  $1.75 
EDWARDS.     Bright's    Disease.     How  a  Person  Affected  with  Bright's  Disease 
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and  Lecturer  on  Pathology  in,  Guy's  Hospital ;  Senior  Physician  to  Evelina  Hos- 
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FILLEBROWN.    A  Text-Book  of  Operative  Dentistry.    Illustrated.    8vo. 

In  Press. 


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Poisons  and  their  Antidotes,  Abbreviations  Used  in  Prescriptions,  and  a  Metric 
Scale  of  Doses.     By  Elias  Longley.        Cloth,  $1.00;  Tucks  and  Pocket,  $1.25 

LIZAB.S.  On  Tobacco.  The  Use  and  Abuse  of  Tobacco.  By  John  Lizars,  m.d. 
i2mo.  Cloth,  .50 

LlfCKES.  Hospital  Sisters  and  their  Duties.  By  Eva  C.  E.  Lucres,  Matron  to 
the  London  Hospital;  Author  of  "  Lectures  on  Nursing."     i2mo.     Cloth,  jjji.cx) 

MAC  MUNII.    On  the  Spectroscope  in  Medicine.    By  Chas.  A.  Mac  Munn,  m.d. 
With  3  Chromo-lithographic  Plates  of  Physiological  and  Pathological  Spectra,* 
and  13  Wood  Cuts.     8vo.  Cloth,  ^^3.00 

MACNAMARA.  On  the  Eye.  A  Manual  of  the  Diseases  of  the  Eye.  By  C. 
Macnamara,  m.d.  Fourth  Edition,  Carefully  Revised;  with  Additions  and 
Numerous  Colored  Plates,  Diagrams  of  Eye,  Wood-cuts,  and  Test  Types. 
Demi  Svo.  Cloth,  ^4.00 

MACDONALD'S  Microscopical  Examinations  of  Water  and  Air.  A  Guide  to  the 
Microscopical  Examination  of  Drinking  Water,  with  an  Appendix  on  the  Micro- 
scopical Examination  of  Air.  By  J.  D.  Macdonald,  m.d.  With  25  Litho- 
graphic Plates,  Reference  Tables,  etc.   Second  Ed.,  Revised.     Svo.   Cloth,  $2.75 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  15 


MACKENZIE  on  the  Throat  and  Xose.  Complete  in  one  octavo  vol.  Including 
the  Pharynx,  Larynx,  Trachea,  Gisophagus,  Nasal  Cavities,  etc.,  etc.  By 
MoKELL  Mackenzie,  m.d..  Senior  Physician  to  the  flospital  for  Diseases  of 
the  Chest  and  Throat,  Lecturer  on  Diseases  of  the  Throat  at  London  Hospital 
Medical  College,  etc.  Revised  and  Edited  by  D.  Hkvson  Delavax,  m.d  ,  Prof, 
of  Laryngology  and  Rhinology  in  the  New  York  Polyclinic  ;  Chief  of  Clinic, 
Department  of  Diseases  of  the  Throat,  Col.  of  Physicians  and  Surgeons.  New 
York;  Sec.  of  the  American  Laryngological  Association,  etc.  One  vol.  Octavo. 
About  800  pages.    Useful  Formulae,  and  over  200  Illustrations.       Nearly  Ready. 

The  (Esophagus,  Nose,  Naso-Pharynx,  etc.  Illustrated.  Being  Vol.  II  of 
the  First  JCdition  of  Dr.  Mackenzie's  Treatise.     Complete  in  itself 

Cloth,  ;?3.C)o;  Leather,  514.00 
The  Fharmacopceia  of  the  Hospital  for  Diseases  of  the  Throat  and  Nose. 
Fourth  Edition,  Enlarged,  Containing  250  Formulae,  with  Directions  for  their 
Preparation  and  Use.     i6mo.  Cloth,  $1.25 

Growths  in  the  Larynx.  Their  History,  Causes,  Symptoms,  etc.  With 
Reports  and  Analysis  of  one  Hundred  Cases.  With  Colored  and  other 
Ilhistrations.     8vo.  Paper,  .75;  Cloth,  J  1.2 5 

MANN'S  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
Diagnosis,  Pathology,  Prognosis  and  Treatment,  including  their  Medico-Legal 
Aspects  ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d., 
member  of  the  New  York  County  Medical  Society.  With  Illustrations  of  Typical 
Faces  of  the  Insane,  Handwriting  of  the  Insane,  and  Micro-photographic  Sec- 
tions of  the  Brain  and  Spinal  Cord.     Octavo.  Cloth,  $5.00;  Leather  $6.00 

MARSHALL  &  SMITH.  On  the  Urine.  The  Chemical  Analysis  of  the  Urine. 
By  John  Marshall,  m.d.,  and  Prof.  Edgar  F.  Smith,  of  the  Chemical  Labora- 
tories, University  of  Pennsylvania.     Phototype  Plates.     i2mo.  Cloth,  $1.00 

MARTIN'S  Microscopic  Mounting.  A  Manual.  With  Notes  on  the  Collection 
and  Examination  of  Objects.  150  Illustrations.  By  John  H.  Martin.  Second 
Edition,  Enlarged.     Svo.  Cloth,  $2.75 

MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d..  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
duction by  Charles  H.  May,  m.d.,  Instructor  in  the  New  York  Polyclinic. 
Numerous  Illustrations.     i2mo.     Being  Medical  Briefs,  No.  'i^.  Cloth,  51.00 

MAYS'  Therapeutic  Forces  ;  or,  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
trine of  Conservation  of  Force.     By  Thomas  J.  Mays,  m.d.  Cloth,  51.25 

Theine  in  the  Treatment  of  Neuralgia.    Being  a  Contribution  to  the  Thera- 
peutics of  Pain.     i6mo.  %  bound.     .50 
MEADOWS'  Obstetrics.     A  Text-Book  of  Midwifery.     Including  the  Signs  and 
Symptoms  of  Pregnancy,  Obstetric  Operations,  Diseases  of  the  Puerperal  State, 
etc.     By  Alfred  Meadows,  m.d.     Third  American,  from  Fourth  London  Edi- 
tion.    Revised  and  Enlarged.     With  145  Illustrations.     Svo.  Cloth,  52.00 

MEDICAL  Directory  of  Philadelphia,  Pennsylvania,  Delaware  and  Southern  half 
of  New  Jersey,  containing  lists  of  Physicians  of  all  Schools  of  Practice,  Dentists, 
Druggists  and  Chemists,  with  information  concerning  Medical  Societies,  Colleges 
and  Associations,  Hospitals,  Asylums,  Charities,  etc.     Morocco,  Gilt  edges,  52.50 

MEIGS.  Milk  Analysis  and  Infant  Feeding.  A  Practical  Treatise  on  the  Ex- 
amination of  Human  and  Cows'  Milk,  Cream,  Condensed  Milk,  etc.,  and 
Directions  as  to  the  Diet  of  Young  Infants.  By  Arthur  V.  Meigs,  m.d..  Physi- 
cian to  the  Pennsylvania  Hospital,  Philadelphia.     i2mo.  Cloth,  51.00 

MEIGS  and  PEPPER  on  Children.  A  Practical  Treatise  on  the  Diseases  of 
Children.  By  J.  Forsyth  Meigs,  m.d..  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc.,  etc.,  and  William  Pepper,  m.d..  Professor  of  the  Principles 
and  Practice  of  Medicine  in  the  Medical  Department,  University  of  Pennsyl- 
vania.    Seventh  Edition.  Cloth,  55.00;  Leather,  56.00 


16  P.  BLAKISTON,  SON  &*  CO:S 

M ERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
the  use  of  Physicians,  Pharmacists  and  Students.  By  Albert  Merrell,  m.d. 
Octavo.  Half  dark  Calf,  $4.00 

MEYER.  Ophthalmology.  A  Manual  of  Diseases  of  the  Eye.  By  Dr.  Edouard 
Meyer,  Prof,  a  L'ficole  de  la  Faculty  de  Medicine  de  Paris,  Chev.  of  the  Legion 
of  Honor,  etc.  Translated  from  the  Third  French  Edition,  with  the  assistance 
of  the  author,  by  A.  Freedland  Fergus,  m.b.,  Assistant  Surgeon  Glasgow 
Eye  Infirmary.  With  270  Illustrations,  and  two  Colored  Plates  prepared 
under  the  direction  of  Dr.  Richard  Liebreich,  m.r.c-s..  Author  of  the  "Atlas 
of  Ophthalmoscopy."     8vo.  ,  Cloth,  I4.50;  Leather,  $5.50 

MILLER  and  LIZAR'S  Alcohol  and  Tobacco.  Alcohol.  Its  Place  and  Power. 
By  James  Miller,  f.r.c.s.  ;  and.  Tobacco,  Its  Use  and  Abuse.  By  John  Lizars, 
M.D.     The  two  essays  in  one  volume.  Cloth,  ;j5i. 00;  Separate,  each  .50 

MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including  the  Outlines 
of  Diagnosis  and  the  Chief  Pathological  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.d.,  m.r.c.p.,  Asst.  Physician  to  the  Hospital  for 
Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital,  Lon- 
don.    Practical  Senes.     See  Page  ig.     i2mo.     560  pages.  Cloth,  ;^3. 00 

MORRIS.  Compend  of  Gynaecology.  By  Henry  Morris,  m.d\,  Demonstrator  of 
Obstetrics,  Jefferson  Medical  College,  Phila.,  etc.  Beitig  ?  Quiz- Compend? 
No.  7.  Nearly  Ready. 

MORTON  on  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy,  and  Test  Types.  By  A.  Morton,  m.b.  Third 
Edition,  Revised  and  Enlarged.  Cloth,  $1.00 

MXTRRELL.  Massage  as  a  Mode  of  Treatment.  By  Wm.  Murrell,  m.d., 
M.R.C.P.,  Lecturer  on  Materia  Medica  and  Therapeutics  at  Westminster  Hospital, 
Examiner  at  University  of  Edinburgh,  Physician  to  Royal  Hospital  for  Diseases 
of  the  Chest.     Third  Edition.     i2mo.  Cloth,  I1.50 

MUTER.  Practical  and  Analjrtical  Chemistry.  By  John  Muter,  f.r.s.,  f.c.s., 
etc.     Third  Edition.     Revised  and  Illustrated.  Cloth,  5^2.00 

OPHTHALMIC  REVIEW.  A  Monthly  Record  of  Ophthalmic  Science.  Published 
in  London.     Sample  Ntimbers,  2j  cents.  Per  annum,  $3.00 

OSGOOD.    The  Winter  and  Its  Dangers.    By  Hamilton  Osgood,  m.d.  Cloth,  .50 

OVERMAN'S  Practical  Mineralogy,  Assaying  and  Mining,  with  a  Description  of 
the  Useful  Minerals,  etc.  By  Frederick  Overman,  Mining  Engineer.  Elev- 
enth Edition.     i2mo.  Cloth,  $1.00 

PACKARD'S  Sea  Air  and  Sea  Bathing.  By  John  H.  Packard,  one  of  the  Phy- 
sicians to  the  Pennsylvania  Hospital,  Philadelphia.  Cloth,  .50 

PAGE'S  Injuries  of  the  Spine  and  Spinal  Cord,  without  apparent  Lesion  and  Ner- 
vous Shock.  In  their  Surgical  and  Medico-Legal  Aspects.  By  Herbert  W. 
Page,  m.d.,  f.r.c.s.     Second  Edition,  Revised.     Octavo.  Cloth,  $3.50 

PAGET'S  Lectures  on  Surgical  Pathology.  Delivered  at  the  Royal  College  of 
Surgeons.    By  James  Paget,  f.r.s.    Third  Edition.    Cloth,  $7.00 ;  Leather,  p.oo 

PARKES'  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  The  Seventh  Re- 
vised and  Enlarged  Edition.     With  Many  Illustrations.     8vo.  Cloth,  $4.50 

PARRISH'S  Alcoholic  Inebriety.  From  a  Medical  Standpoint,  with  Illustrative 
Cases  from  the  Clinical  Records  of  the  Author.  By  Joseph  Parrish,  m.d., 
President  of  the  Amer.  Assoc,  for  Cure  of  Inebriates.      Paper,  .75 ;  Cloth,  JJ51.25 

PARVIN'S  Winckel's  Diseases  of  Women  (see  Winckel-Parvin,  page  24). 

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PENNSYLVANIA  Hospital  Reports.  Edited  by  a  Committee  of  the  Hospital 
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by  the  Staff.     With  many  other  Illustrations.  Paper,  .75;  Cloth,  $1.25 


MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  17 


PHYSICIAN'S  VISITING  LIST.  Published  Annually.  Thirty-eighth  Year  of  its 
Publication. 

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100  "  "  "  "  "  <<  •!  _  2.00 

•<  !■  -.       1  (Jan.  to  June)  ,,         ,,         ,, 

5°                         -  ^°^^-  i  July  to  Dec.  \  '         '  ^.50 

,,  ,,  ,  (Jan.  to  June  I  ,,         .,         u 

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,,  <<  ^      1       ( Jan.  to  June )      ,,        , .  ,^ 

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•'  ( July  to  Dec.  j  -^ 

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PEREIRA'S  Prescription  Book.  Containing  Lists  of  Terms,  Phrases,  Contrac- 
tions and  Abbreviations  used  in  Prescriptions,  Explanatory  Notes,  Grammatical 
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PHILLIPS'  Materia  Medica  and  Therapeutics.  "Vegetable  Kingdom.  Organic 
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don.    Second  Edition  (Complete).     Enlarged  and  Revised.  Cloth,  55.00 

PIGGOTT  on  Copper  Mining  and  Copper  Ore.  With  a  full  Description  of  the 
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POLYCLINIC,  The.  A  Monthly  Journal  of  Medicine  and  Surgery.  Edited  by 
Henry  Leffmann,  m.d.  32  pages,  monthly.  Now  in  its  5th  Volume.  Royal 
8vo.     Sample  Numbers  free.  Per  annum,  $1.00. 

POWER,  HOLMES,  ANSTIE  and  BARNES  (Drs.).  Reports  on  the  Progress  of 
Medicine,  Surgery,  Physiology,  Midwifery,  Diseases  of  Women  and  Children, 
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POTTER.  A  Handbook  of  Materia  Medica,  Pharmacy  and  Therapeutics,  in- 
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cisco  ;  late  A.  A.  Surgeon  U.  S.  Army.  Cloth,  $3.00;  Leather,  53-50 

Speech  and  Its  Defects.  Considered  Physiologically,  Pathologically  and 
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Revised  and  Corrected.     i2mo.  Cloth,  51.00 

Compend  of  Anatomy,  including  Visceral  Anatomy,  formerly  published 
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and  117  Illustrations.     Being  No.  j  ?  Quiz- Compend  f  Series.       Cloth,  51.00 

Interleaved  for  taking  Notes,  51.25 


18  P.  BLAKISTON,  SON  &^  CO:S 

POTTER.  Compend  of  Materia  Medica,  Therapeutics  and  Prescription  Writ- 
ing', arranged  in  accordance  with  the  last  Revision  U.  S.  Pharmacopoeia,  with 
special  reference  to  the  Physiological  Action  of  Drugs.  Fifth  Revised  and 
Improved  Edition,  with  Index.     Being  No.  6  ?  Quiz- Compend?  Series. 

Cloth,  $i.oo.     Interleaved  for  taking  Notes,  $1.25 

PRINCE'S  Plastic  and  Orthopaedic  Surgery.  By  David  Prince,  m.d.  Contain- 
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Surgery,  etc.      Numerous  Illustrations.     8vo.    •  Cloth,  #4.50 

PRITCHARD  on  the  Ear.  Handbook  of  Diseases  of  the  Ear.  By  Urban 
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ants, etc.  By  Walter  Pye,  m.d..  Surgeon  to  St.  Mary's  Hospital,  London. 
208  Illustrations.  Cloth,  $5.00 

RADCLIFFE  on  Epilepsy,  Pain,  Paralysis,  and  other  Disorders  of  the  Nervous 
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RALFE.  Diseases  of  the  Kidney  and  Urinary  Derangements.  By  C.  H.  Ralfe. 
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THE   PRACTICAL  SERIES. 

THREE   NEW   VOLUMES,  JUST  ISSUED. 


LEWERS.  On  the  Diseases  of  Women.  A  Practical  Treatise.  By  Dr.  A.  H. 
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WATTS'  Inorganic  Chemistry.     A  Manual  of  Chemistry,  Physical  and  Inorganic. 

(Being  the  13th  Edition  of  Fowne's  Physical  and  Inorganic  Che.mistry.) 

By  Henry  Watts,  b.a.,  f.r.s..  Editor  of  the  Journal  of  the  Chemical  Society; 

Author  of  "A  Dictionary  of  Chemistry,"  etc.     With  Colored  Plate  of  Spectra 

and  other  Illustrations.     i2mo.     595  pages.  Cloth,  52.25 

Organic  Chemistry.     Second  Edition,     By  Wm.  A.  Tilden,  d.sc,  f.r.s. 

(Being  the  13th  Edition  of  Fowne's  Organic  Chemistry.)     Illustrated. 

i2mo.  Cloth,  52.25 

WELCH'S  Enteric  Fever.  Its  Prevalence  and  Modifications;  ^^tiology,  Pathology 
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WHITE.    The  Mouth  and  Teeth.    By  J.  W.  White,  m.d.,  d.d.s.    Editor  of  the 

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WICKES'  Sepulture.     Its  History,  Methods  and  Sanitary  Requisites.    By  Stephen 

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WILLIAMS.    Pulmonary  Consumption.    Its  Etiology,  Pathology  and  Treatment, 

with  an  Analysis  of  1000  Cases  to  Exemplify  its  Duration  and  Modes  of  Arrest. 

By  C.  J.  B.  Williams,  m.d.    Second  Edition.    Enlarged  and  Rewritten.    By  C. 

Theodore  Williams,  m.d.      With  4  Colored  Plates  and  other  Illustrations. 

Octavo.  Cloth,  5.00 


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Demi-Ootavo.    Frioe  of  eaoli  book,  Cloth,  $3.00 ;  Leather,  $3.50. 

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Cloth,  ^3.00;  Leather,  ^3.50 

YEO'S  MANUAL  OF  PHYSIOLOGY.  Third  Edition.  A  New  Text-book  for  Students.  By 
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PARVIN'S-WINCKEL'S  DISEASES  OF  WOMEN.  A  Treatise  on  the  Diseases  of  Women.  By 
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Illustrated  by  117  fine  Engravings  on  Wood,  most  of  which  are  new.     674  pp. 

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POTTER'S  MATERIA  MEDICA,  PHARMACY  AND  THERAPEUTICS.  A  Handbook  of 
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RICHTER'S  ORGANIC  CHEMISTRY.  By  Prof.  Victor  von  Richter,  University  of  Breslau. 
Authorized  translation.  First  American,  from  the  Fourth  German  Edition.  By  Edgar  F.  Smith,  M.A., 
PH.D.,  Translator  of  Richter's  Inorganic  Chemistry;  Prof,  of  Ciiemistry  in  Wittenberg  College,  Spring- 
field, Oiiio;  formerly  in  the  Laboratories  of  the  University  of  Pennsylvania;  Member  of  the  Chemical 
Societies  of  Berlin  and  Paris,  of  the  Academy  of  Natural  Sciences  of  Philadelphia,  etc.  Illustrated. 
710  pages.  Cloth,  ^3.00;  Leather,  ^3.50 

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Professor  of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania;  late  President 
of  the  Medical  Jurisprudence  Society  of  Philadelphia;  Physician  to  St.  Joseph's  Hospital;  Member  of 
the  College  of  Physicians  of  Phila  ;  Corresponding  Member  of  the  New  York  Medico-Legal  Society,  etc. 
2d  Edition.      Revised  and  Enlarged.     654  pages.  Cloth,  ^3.00;  Leather,  ^^3.50 

WARING'S  PRACTICAL  THERAPEUTICS.  Fourth  Edition.  A  Manual  of  Practical  Thera- 
peutics, considered  with  reference  to  Articles  of  the  Materia  Medica.  Containing,  also,  an  Index  of 
Diseases,  with  a  list  of  the  Medicines  applicable  as  Remedies,  and  a  full  Index  of  the  Medicines  and 
Preparations  noticed  in  the  work.  By  Edward  John  Waring,  m.d.,  f.r.c.p.,  f.l.s.,  etc.  4th 
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JUST  PUBLISHED.     SECOND  EDITION. 

HUMAN  PHYSIOLOGY. 

By  LANDOIS  and  STIRLING. 

Wifh  nearly  600  lllustraiions. 

SECOND    AMERICAN,    FROM    THE    FIFTH    GERMAN     EDITION. 

A  Text-Book  of  Human  Physiology,  including  Histology  and  Microscopical  Anatomy, 
with  special  reference  to  the  requirements  of  Practical  Medicine.  By 
Dr.  L.  L.ANDOis,  Professor  of  Physiology  and  Director  of  the  Physiological  Institute, 
University  of  Greifswald.  Translated  from  the  Fifth  German  Edition,  with  addi- 
tions by  Wm.  Stirling,  m.d.,  sc.d.,  Brackenburg,  Professor  of  Physiology  and 
Histology  in  Owen's  College  and  Victoria  University,  Manchester;  Examiner  in 
the  Honors'  School  of  Science,  University  of  Oxford,  England.  Second  Edition, 
revised  and  enlarged.     583  Illustrations. 

"A   BRIDGE    BETWEEN    PHYSIOLOGY    AND    PRACTICAL    MEDICINE." 

One  Volume.    Royal  Octavo.    Cloth,  $6.50 ;  Leather,  $7.50. 

From  the  Prefaces  to  the  English  Edition. 
The  fact  that  Prof.  Landois'  book  has  passed  through  four  large  editions  in  the  original  since  1880,  and 
that  in  barely  six  months'  time  a  second  edition  of  the  English  has  been  called  for,  shows  that  in  some 
special  way  it  has  met  a  want.  The  characteristic  which  has  thus  commended  the  work  will  be  found 
mainly  to  lie  in  its  eminent  practicability;  and  it  is  this  consideration  -vhichhas  induced  me  to  undertake  the 
task  of  putting  it  into  English.  Landois'  work,  in  fact,  forms  a  Bridge  between  Physiology  and  the  Practice 
of  Medicine.  It  never  loses  sight  of  the  fact  that  tlie  student  of  to  day  is  the  practicing  physician  of 
to-morrow.  In  the  same  way,  the  work  offers  to  the  busy  physician  in  practice  a  ready  means  of  refreshing 
his  memory  on  the  theoretical  aspects  of  Medicine.  lie  can  pass  backward  from  the  examination  of  patho- 
logical phenomena  to  the  normal  processes,  and,  in  the  study  of  these,  find  new  indications  and  new  lights 
for  the  appreciation  and  treatment  of  the  cases  under  consideration.  With  this  object  in  view,  all  the 
methods  of  investigation  which  may,  to  advantage,  be  used  by  the  practitioner,  are  carefully  and  fully 
described.  Many  additions,  and  about  one  hundred  illustrations,  have  been  introduced  into  this  second 
English  edition,  and  the  whole  work  carefully  revised. 

PRESS  NOTICES. 

"Most  effectiv;ly  aids  the  busy  physician  to  trace  from  morbid  phenomena  back  the  course  of  divergence  from 
healthy  physical  operations,  and  to  gather  in  this  way  new  lights  and  novel  indications  for  the  comprehension  and  tkeatment 
ot  the  maladies  with  which  he  is  called  upon  to  cope." — American  Journal  (jf  Uledical  Sciences. 

"  I  know  of  no  book  which  is  its  equal  in  the  applications  to  the  needs  of  clinical  medicine." — Pro/.  Harrison  Allen,  lai* 
Professor  ff  Physioloi^y,  University  of  Pennsylvania. 

"  We  have  no  hesitation  in  saying  that  this  is  the  work  to  which  the  Practitioner  will  turn  whenever  he  desires  light 
thrown  upon  ilie  phenomena  of  a  complicated  or  important  case." — Edinburgh  Medical  Journal. 

"  So  great  are  the  advantages  oflfered  by  Prof.  Landois'  Text- Book,  from  the  exhaustive  and  bminrntly  practical 
manner  in  which  the  subject  is  treated,  that  it  has  passed  through  four  large  editions  in  the  same  nuniber  of  years.  .  .  . 
Dr.  Stirling's  annotations  have  materially  added  to  the  value  of  the  work.  Admirably  adapted  for  the  Practitkinkr.  .  .  . 
With  this  Text-book  at  command,  NO  Student  could  fail  in  his  examination." — The  Lancet. 

"One  of  the  mkST  practical  works  on  Physiology  ever  written,  forming  a  '  bridge  '  between  Physiology  and  Practical 
Medicine.  .  .  .  Its  chief  merits  are  its  completeness  and  conciseness.  .  .  .  The  additions  by  the  Editor  are  able  and  judicious. 
.  .  .  Excellently  clear,  attractive  and  succinct." — British  Medical  Journal. 

"  The  great  subjects  dealt  with  are  treated  in  an  admirably  clear,  terse,  and  happily  illustrated  manner." — Practitioner. 

"Unquestionably  the  most  admirable  exposition  of  the  relations  of  Human  Physiology  to  Practical  Medicine  ever  laid 
before  English  readers" — Students'  Journal. 

"  As  a  work  of  reference,  Landois  and  Stirling's  Treatise  ought  to  take  the  foremost  place  among  the  text- 
books in  the  Engli'^h  language.     The  wood-cuts  are  noticeable  for  their  number  and  beauty." — (^last^tnn  Medical  Journal. 

"  Landois'  Physiology  is,  without  question,  the  best  text-book  on  the  subject  that  has  ever  been  written." 
— Neiu   York  Medical  Record. 

"  The  chapter  on  the  Brain  and  Spin.-il  Cord  will  be  a  n"ost  valu.able  one  for  the  general  reader,  the  tran!;l:itor's  notes  adding 
not  a  little  to  its  importance.  The  sections  on  Sight  and  Hearing  are  exhaustive.  .  .  .  The  Chemistry  of  the  Urine  is  thoroughly 
considered.  ...  In  its  present  form,  the  value  of  the  original  h.is  been  greatly  increased.  .  .  .  The  text  is  smooth,  accurate, 
and  unusually  fiee  from  tjermanisms  ;  in  fact,  it  is  good  English." — Ne-w  York  Medical  Journal. 

"  It  is  not  for  the  physiological  student  alone  that  Prof.  Landois'  book  possesses  great  value,  for  tt  has  bfen  addresskii 
TO  the  practitioner  of  medicine  as  well,  who  will  find  here  a  direct  application  of  physiological  to  pathological  processes." 
Af-dical  liulletin. 

P.  BLAKISTON,  SON  &  CO.,  Publishers,  1012  Walnut  St.,  Philadelphia. 


JUST  READY.     A  TEXT-BOOK  OF 


DISEASES  OF  THE  EYE. 

BY  DR.  EDOUARD  MEYER, 

Prof,    i  V Kcole  Pratique  de  la  Faculte  de  Medecine  de  Pai'is ;    Chevalier  of  the  Legion  of  Honor,  etc. 

AUTHORIZED    TRANSLATION   BY 

FREELAND  FERGUS,  M.  B.,  Assistant  Surgeon,  Glasgow  Eye  Infirmary. 

COLORED   PLATES   PRINTED   UNDER  THE   DIRECTION  OF 

DR.   RICHARD  LIEEREICH,  M.  R.  C.  S.,  Author  of  the  "Atlas  of  Ophthalmoscopy." 

WITH  COLORED  PLATES  AND  267  ENGRAVINGS  ON  WOOD. 

Octavo.     650  Pages.     Cloth,  $4.50  ;    Leather,  $5.50. 

Synopsis  of  Contents. — Diagnosis  and  Treatment  of  Ocular  Affections.  Diseases  of  the  Conjunc- 
tiva. Diseases  of  the  Cornea  and  Sclerotic.  Iris — Ciliary  Body — Choroid.  Glaucoma.  Diseases  of  the 
Optic  Nerve  and  Retina.  Amblyopia  and  Amaurosis.  Diseases  of  the  Vitreous  Body.  Diseases  of  the 
Crystalline  Lens.  Refraction  and  Accommodation.  The  Muscles  of  the  Eye.  Diseases  of  the  Eyelids. 
Diseases  of  the  Lachrymal  Passages.     Diseases  of  the  Orbit.     Table  of  Dioptrics.     Index. 


Fig.  27.— Pterygium. 


Forming  a  complete  systematic  Manual  of  Ophthalmology.     The  translating 

and  editing  have  been  done  with  the  assistance 
of  the  author.  The  illustrations,  which  will  be 
found  of  great  help  in  diagnosis,  have  been  care- 
fully engraved ;  the  colored  plates,  being  re- 
duced from  Liebreich's  Atlas  of  Ophthalmology 
and  printed  under  the  direction  of  Dr.  Liebreich, 
are  accurate  and  faithful  representations  of  their 
subjects. 

Treatment  and  Diagnosis  receive  full  share 
of  attention.       Refraction    and   accommodation 
(Attention  is  called  to  the  help  in  diagnosis  of  a    occupy  a   scction    of   ovcr  sixty    pagcs,  being 
cut  of  this  character.   It  is  followed  by  three  en-    handled   in  a  practical,   concisc   way   that  will 

gravings  showing  the  operation  for  Pterygium.)  .  ,        ,  . 

commend  itself  specially  to  students  and  physi- 
cians who  have  given  the  subject  but  little  attention.  The  chapters  describing  the 
subject  of  general  diagnosis  and  the  proper  instruments  to  be  used,  are  thorough 
and  well  illustrated. 

Dr.  Swan  M.  Burnett,  reviewing  the  book  in  Tke  Archives  of  Ophthalmology,  says  :    "  The  cause  of  its  popularity  is  not 
far  to  seek.     It  is  clear,  concise,  conservative  and  eminently  practical." 

This  book  has  gone  through  three  French  and  four  German  Editions, 
has  been  translated  into  Italian,  Spanish,  Polish,  Russian,  Japanese — 
this,  the  English  Edition,  making  the  eighth  language  in  which  it  has 
been  published. 

P.  Blakiston,  Son  &  Co.,  Publishers,  1012  Walnut  Street,  Philadelphia. 


COWERS' 

DISEASES  OP  THE  NERVOUS  SYSTEM. 

Complete  in  One  Large  Octavo  Volume.    1360  Pages.    341  Illustrations,  con- 
taining over  700  Figures.    Price  in  Cloth,  $6  50  ;  in  Leather,  $7.50. 


A  COMPLETE  TEXT-BOOK.  By  William  R.  Gowers,  m.d.,  Professor  Clinical 
Medicine,  University  College,  London,  Physician  to  University  College  Hospital 
and  to  the  National  Hospital  for  Paralyzed  and  Epileptic,  etc. 

Published  by  special  arrangement  with  the  author,  and  containing  all  the  mate- 
rial in  the  two-volume  English  edition,  with  some  corrections  and  additions.  This  is 
probably  the  most  exhaustive  book  ever  published  on  Nervous  Diseases.  The 
author's  breadth  of  scope,  systematic  and  interesting  style,  combine  to  make  his 
work  one  of  the  most  useful  that  has  been  published  in  any  branch  of  medicine. 


"  The  work,  therefore,  while  serving  to  initiate  the  general  reader  in  the  elements  of  that  science,  ranks  higher 
than  a  more  textbook  on  the  subject.  The  author's  object  has  been,  in  our  opinion,  skillfully  and  successfully 
carried  out,  and  a  perusal  and  study  of  this  will  place  the  student  and  practitioner  in  possession  of  all  the  leading 
and  essential  facts  necessar>'  to  investigate  and  treat  diseases  of  the  nervous  system  according  to  the  most  recent 
improvements  of  our  knowledge  at  the  present  day." — British  Medical  Journal. 

"It  maybe  said,  without  reserve,  that  this  work  is  the  most  clear,  concise  and  complete  text-book  upon  diseases 
of  the  nervous  system  in  any  language.  And  when  the  large  number  of  such  works  which  has  appeared  in  Ger- 
many, France  and  England  within  the  past  ten  years  is  considered,  this  implies  high  praise." — American  Journal 
Medical  Science ,  June ,  iSSS. 

"  It  would  be  invidious  to  praise  one  part  more  than  another,  where  all  is  so  good.  Brevity  and  conciseness, 
combined  with  completeness  and  the  most  absolute  clearness,  are  the  characteristics  of  the  work.  T.iken  as  a 
whole,  it  promises  to  be  the  most  useful  work  on  diseases  of  the  nervous  system  which  we  possess." — Dublin 
Journal  0/ Medical  Sciences. 

"The  student  and  practitioner  will  find  in  it  a  true  friend,  guide  and  helper  in  his  studies  of  the  diseases  of 
the  nervous  system.  It  is  a  most  complete  manual,  presenting  a  thor',ugh  reflex  of  the  present  state  of  know- 
ledge of  the  diseases  of  the  nervous  system.  The  care  and  thought  that  have  been  bestowed  on  its  production 
are  evident  on  every  page.  In  the  presence  of  such  ability,  learning  and  originality,  criticism  can  only  take  a 
favorable  direction.  The  style  and  manner  are  accurate,  studied  and  adequate — never  diffuse.  The  illustrations 
call  for  special  notice.  They  are  numerous,  new  and  original.  No  better  manual  on  nervous  disAses  has  been 
presented  to  the  medical  profession." — London  Lancet, 

"  From  a  small  beginning  a  great  work  has  gradually  been  evolved.  Less  than  ten  years  ago  Gowers  put  out 
a  very  modest  little  book  on  the  '  Diagnosis  of  Diseases  of  the  Spinal  Cord,'  which  was  soon  followed  by  an 
equally  modest  treatise  on  '  Diseases  of  the  Brain.'  Two  years  ago  the  first  half  of  this  manual  appeared,  com- 
prising Diseases  of  the  Spinal  Cord  and  Nerves,  and  now  this  manual  of  Diseases  of  the  entire  Nervous  System 
is  placed  before  us.  Cowers'  manual  is  herewith  recommended  to  the  general  and  to  the  special  student.  It  is 
not  too  detailed  for  the  former,  while  for  the  specialist  it  is  explicit  enough  as  a  first-class  book  of  reference.  It 
is,  on  the  whole,  an  admirable  treatise." — journal  of  Nervous  and  Menial  Diseases,  Netv  York,  May,  jSSS. 

*  *  *  "  The  contents  is  so  vast  as  to  make  it  impossible,  in  a  review,  to  enumerate  the  subjects  handled  by 
the  author,  far  less  to  attempt  an  analysis  and  discussion  of  the  views  held  by  him  on  the  numerous  problems 
with  which  he  has  to  deal.  We  shall  limit  ourselves,  therefore,  almost  entirely  to  a  statement  of  the  leading 
features  of  this  manual,  that  characterize  it  as  one  of  the  very  best  published  in  any  langu.ige.  *  *  •  What 
we  admire,  first,  is  the  clearness  of  thought  and  language  in  the  exposition,  even  in  the  most  difficult  portions 
of  the  subject.  It  is  not  every  one  who,  being  a  master,  is  at  the  same  time  a  skillful  expounder,  and  knows 
how  to  elucidate,  whilst  condensing,  his  theme.  Secondly,  we  find  the  evidence  on  every  page  of  the  book  of 
the  author's  individual  familiarity  with  the  topics  he  is  discussing.  •  •  •  Finally,  we  note  the  thorough  mas- 
tery of  the  author  of  the  most  recent  researches."— .5rai«,  Lyndon,  /SS3. 

P.  BLAKISTON,  SON  &  CO., 

I>ul>lislier8,  101X3  "W^alnut  Street,  PbUadelpliia,  I»». 


A  NEW^  TEXT-BOOK  JUST  PUBLISHED. 

DISEASES  OF  THE  SKIN. 

BY  T.  MCCALL  ANDERSON,  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Glasgow. 
ASSISTED  BY 
Dr.  James  Christie,  Sec'y  London  Epidemiological  Society  for  Indian  Ocean  and  East  Africa ;  Mem. 
Medical  Soc.  of  Bombay,  etc.  Dr.  Hector  C.  Cameron,  Surgeon  and  Lecturer  to  Western  Infirmary, 
Glasgow;  Surgeon  to  Glasgow  Hospital  for  Children,  etc.  William  Macewen,  m.b.,  m.d.,  Lecturer  on 
Systematic  and  Clinical  Surgery,  Royal  Infirmary ;  Surgeon  to  Royal  Infirmary  and  Children's  Hospital, 
Glasgow,  etc. 

WITH  COLORED  PLATES  AND  NUMEROUS  WOOD  ENGRAVINGS. 

Octavo.     650  Pages.     Cloth,  $4.50  ;  Leather,  $5.50. 

A  treatise  on  Diseases  of  the  Skin,  with  reference  to  Diagnosis  and  Treatment, 
including  an  Analysis  of  11,000  Consecutive  Cases.  Thoroughly  illustrated  by  new  and 
handsome  wood  engravings,  and  several  colored  and  steel  plates  prepared,  under  the 
direction  of  the  author,  from  special  drawings  by  Dr.  John  Wilson. 

PARTICULARLY  STRONG  IN  TREATMENT. 

B@°"  Special  attention  is  given  to  the  Differential  Diagnosis  of  Skin  Diseases  and  to  the 
treatment.  There  are  over  150  prescriptions,  which  will  serve  as  hints  to  the  physician 
in  dealing  with  obstinate  and  chronic  cases. 

There  has  been  no  complete  treatise  on  Dermatology  issued  for  several  years  ;  Professor 
Anderson  has,  therefore,  chosen  an  opportune  time  to  publish  his  book. 


Illustrating  one  of  the  Diseases  of  the  Hair  (See  Fig,  b,^age  7). 

For  nearly  twenty-five  years  Professor  Anderson  has  been  a  general  practitioner  and  a 
hospital  physician,  with  unusual  opportunities  for  the  study  of  this  class  of  diseases,  though 
not  a  "specialist,"  as  the  term  is  understood.  His  experience  is,  therefore,  of  great 
value,  and  the  physician  will  feel  that,  in  consulting  this  work,  he  is  reading  the  expe- 
riences of  a  man  situated  as  himself — with  the  same  difficulties  of  diagnosis  and  treatment, 
and  who  has  surmounted  them  successfully.  We  believe  this  to  be  a  valuable  feature  of 
the  book  that  will  be  recognized  at  once ;  for  it  is  undoubtedly  a  fact  that  a  work  like 
the  present  contains  much  practical  information  and  many  hints  not  to  be  found  else- 
where. Professor  Anderson  is  particularly  happy  in  illustrating  the  impor- 
tant relations  subsisting  between  the  general  economy  and  its  covering,  and 
his  ideas  of  pathology  and  therapeutics,  including  a  consideration  of  all  the  general, 
and  local  manifestations  of  the  common  diseases  of  the  economy  which  are  manifested 
upon  the  surface,  will  find  many  appreciative  readers. 

Diseases  of  the  hair  receive  full  systematic  treatment. 

"  We  welcome  Dr.  Anderson's  work  not  only  as  a  friend,  but  as  a  benefactor  to  the  profession,  because  the  author  has  ; 
stricken  off  mediaeval  shackles  of  insuperable  nomenclature  and  made  crooked  ways  straight  in  the  diagnosis  and  treatment  of 
this  hitlTierto  but  little  understood  class  of  diseases.  The  chapter  on  Eczema  is,  alone,  worth  the  price  of  the  book." — Nashville 
Altdical  News.  ^ 

P.  Blakiston,  Son  &  Co.,  Publishers,  1012  Walnut  Street,  Philadelphia. 


JUST    READY. 

THE    SEVENTH    REVISED    AND    ENLARGED    EDITION 

OF 

ROBERTS'  PRACTICE. 


THE  THEORY  AND    PRACTICE    OF  MEDICINE.     By  Fred. 
T.  Roberts,  m.d.,  k.r.c.p.,  Professor  of  Materia  Mcdica  and  Therapeu- 
tics at  University  Hospital,  Physician  to  Univcrs-.*^  College  Hospital,  etc. 
Seventh  Edition.     Revised  and  Enlarged.     One  vo.."'nr>e,  8vo.,  with  nu- 
merous Illustrations.  Cloth  Binding,  $5.50;  Leather,  $6.50 
The  present  edition  has  been  fully  revised  throughout,  and  in  some  parts  rewritten  or  re- 
arranged.    While  an  endeavor  has  been  made  to  bring  every  subject  up  to  date  in  all  its  aspects, 
special  attention  has  been  given  to  the  questions  of  treatment,  with  the  view  of  bringing  into 
notice  important  therapeutic  agents  or  methods  which  have  been  recently  introduced. 

The  unexceptional  large  and  rapid  sale  of  this  book,  and  the  universal  commendation  it  has 
received  from  the  profession,  seems  to  be  a  sufficient  guarantee  of  its  merit  as  a  Text-book.  The 
publishers  are  in  receipt  of  numerous  letters  from  professors  in  the  medical  schools,  speaking 
favorably  of  it,  and  below  they  give  a  few  extracts  from  the  medical  press,  American  and 
English,  attesting  its  superiority  and  value  to  both  student  and  practitioner.  The  present  edi- 
tion  has  been  thoroughly  revised  and  much  of  it  re- written. 

"  The  best  Text-book  for  students  in  the  English  language.  We  know  of  no  work  in  the 
English  language,  or  in  any  other,  which  competes  with  this  one." — Edinburgh  Medical  Journal. 

"  Dr.  Roberts'  book  is  admirably  fitted  to  supply  the  want  of  a  good  Handbook,  so  much 
felt  by  every  medical  student." — Student's  Journal  and  Hospital  Gazette. 

"There  are  great  excellencies  in  this  book,  which  will  make  it  a  favorite  with  the  student." 
— Richmond  and  Louisville  Journal. 

"  We  heartily  recommend  it  to  students,  teachers,  and  practitioners." — Boston  Medical  and 
Surgical  Journal. 

"  It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands  as  a  compendium  for  students." 
The  Clinic. 

"  We  particularly  commend  it  to  students  about  to  enter  upon  the  practice  of  their  profession." 
— St.  Louis  Medical  and  Surgical  Journal. 

"  If  there  is  a  book  in  the  whole  of  medical  literature  in  which  so  much  is  said  in  so  few 
words,  it  has  never  come  within  our  reach." — Chicago  Medical  Journal. 

BY  THE  SAME  AUTHOR. 
NOTES   ON  MATERIA  MEDICA  AND  PHARMACY. 

ESPECIALLY    ARRANGED    FOR    THE    USE    OF   STUDENTS. 

16mo,  Cloth,  $2.00. 

For  sale  by  all  Booksellers ;  or  will  be  sent  by  mail,  postpaid,  on  receipt  of  price 
by  the  Publishers, 

P.  BlakIston,  Son  &  Co.,  1012  Walnut  Street,  Philadelphia. 


PERIODICALS  PUBLISHED  BY  P.  BLAKISTON,  SON  &  CO. 

THE   POLYCLINIC.     Vol.  VL 

A  Monthly  Journal  of  Medicine  and  Surgery.  Doubled  in  Size  Without  Increase  of  Price. 

$i.oo  PER  ANNUM.      SAMPLE  COPIES  FREE. 

EDITOR-IN-CHIEF,    HENRY    LEFFMANN,    M.  D. 

Tlie  Polyclinic  contains 

More  original  and  clinical  articles  prepared  especially  for  it  by  prominent  writers  than  any  other 
Medical  Journal  of  its  size  and  price.  Arrangements  have  been  made  to  secure  reports  of  clinics 
by  well-known  lecturers  in  New  York,  Chicago  and  other  cities,  as  well  as  in  Philadelphia.  A 
special  department  of  Therapeutics  has  been  added,  in  which  will  be  described  the  action  of 
new  remedies  and  newly-discovered  action  of  old  drugs;  also  a  department  of  Clinical  Ab- 
stracts from  foreign  journals.  Both  departments  are  in  charge  of  men  selected  for  their  special 
fitness  for  the  purpose. 

REGULAR  CONTRIBUTORS.— Chas.  H.  Burnett,  m.d.  (Oio/ogy),  Arthur  Ym  Har- 
lingen,  m.d.  {Skin  Diseases),  John  B.  Roberts,  m.d.  {Surgery),  Thos.  J.  Mays,  M.D.  {Therapeu- 
tics), J.  Henry  C.  Simes,  m.d.  {Surgery),  Chas.  K.  Mills,  M.D.  {Nervous  Diseases),  and  others. 

Clinical  Lectures,  Papers  and  Original  Articles  appeared  by  the  following  gentlemen  during 
1887:— 

Goodell  (Prof.  Wm.),  Univ.  of  Penna. 
Meigs  (Dr.  A.  V.),  Phys.  to  Penna,  and  Child.  Hosp. 
Osier  (Prof.  Wm.),  Univ.  of  Penna. 
Willard  (Dr.  DeForest). 
Mittendorf  (Dr.  VV.  M.),  Surg,  to  N.  Y.  Eye  and  Ear 

Infirmary. 
Sinkler  (Dr.  Wharton),  Phys.  to  Orth.  Hosp. 
Browne  (Lenno.x,  f.k.c  s.),  London. 
Brubaker  (Dr.  A.  P.),  Dera.  of  Physiology,  Jefferson 

Med.  Coll. 
Steele  (D.  A.  K.,  m.d.).  Prof.  Orth.  Surg.,  Coll.  Phys. 

and  Surg.,  Chicago. 
McMurtrie  (Dr.  L.  S.),  Danville,  Ky. 
Tyson  (Dr.  Jas.),  Prof.  Pathology,  Univ.  of  Penna. 
Hartshorne  (Dr.  Henry). 
DaCosta  (Dr   John  C  ),  Gynjecologist  to  Jeff.  Med. 

Coll.  Hosp. 
Henry  (Dr.  F.  P.),  Phys.  to  Episcopal  Hospital,  Phila. 

A.  SPECIAL    OFFER.  '^^  &^ch.  new  subscriber,  who  remits  one  dollar,  in 

I - .1      advance,  we  will  send  The  Polyclinic  for  one 

year  and  A  copy  of  either  of  the  following  books  : — 

Urinary  and  Renal  Derangements  and  Calculous  Disorders,  with  Hints 

on  Diagnosis  and  Treatment,  by  Lionel  S.  Beale,  m.d.,  i2mo,  356  pages; 
Roberts'  Materia  Medica,  i6mo,  388  pages;  or 
Thompson's  Surgery  of  the  Urinary  Organs,  8vo,  150  pages. 

The  Journal  of  Laryngology  and  Rhinology. 

An  Analytical  Ra«i»rd  of  Current  Literature  Relating  to  the  Throat  and  Nose.    Edited  by  MORELL 
MACKENZIE,  M.D.,  Lond.,  and  R,  NORRIS  WOLFENDEN,  M.D.,  Cantab. 

With  the  Co-operation  of  Dr.  Fauvel  (Paris),  Dr.  Joal  (Paris),  Prof.  Massei 
(Naples),  Prof.  GuvE  (Amsterdam),  Dr.  Capart  (Brussels),  Dr.  Hunter  Mackenzie 
(Edinburgh),  Dr.  Michael  (Hamburg),  Dr.  Ramon  de  la  Sota  y  Lastra  (Seville), 
Dr.  John  N.  Mackenzie  (Baltimore),  Dr.  Holger  Mygind  (Copenhagen),  Dr. 
Smyly  (Dublin),   and  Dr.  Greville  Macdonald  (London). 

PUBLISHED    MONTHLY.     PER  ANNUM,  $3.00.  SAMPLE  NUMBERS  25c. 

"the  ophthalmic  reviewT 

A  Monthly  Record  of  Ophthalmic  Science. 

Edited  by  JAMES  ANDERSON,  M.D.,  London  ;  KARL  GROSSMANN,  Liverpool;  PRIESTLEY 

SMITH,  Birmingham,  and  JOHN  B.  STORY,  M.D.,  Dublin. 

MONTHLY.      SUBSCRIPTION  PER  ANNUM  $3.00. 

The  Ophthalmic  Review  is  the  only  Journal  devoted  to  this  special  branch  of 
medicine  that  is  published  in  Great  Britain,  and  therefore  represents  the  advances 
made  in  that  country  as  no  other  periodical  can.     Sample  numbers  23  cents. 


Bantock  (Geo.  Granville,  f.r.c.s.),  London. 

Pepper  (Wm.,  m.d.).  Prof.  Pract.of  Med.,Univ.  of  Pa, 

Carter  (Dr.  Landon  Gray),  Prof,  of  Men.  and  Nerv. 

Dis.,  N.  Y.  Polyclinic. 
Robison  (Dr.  John  A.),  Rush  Med.  Coll.,  Chicago. 
Pavy  (F.  W.,  f.r.s.)",  London. 

Price  (Dr.  Joseph),  Phys.  to  Preston  Retreat,  Phila. 
Longstreth   (Dr.  Morris),   Pathologist  to  Jefferson 

Med.  Coll. 
AVhite  (Wm.  Hale,  m.d.),  Guy's  Hospital,  London. 
Ashhurst  (John,  Jr.),  Prof.  Clin.  Surg.,  Univ.  of  Pa. 
Packard  (Dr.  John  H.),  Surg   to  Penna.  Hospital. 
Parvin  (Theophilus),  Prof.  Obst.  and  Dis.  of  Women, 

Jefferson  Med.  Coll. 
Wyeth  (John  A.),  Prof,  of  Surg.,  N.  Y.  Polyclinic. 
Reese   (Dr.  John  J.),  Prof,  of  Med.  Jurisprudence, 

Univ.  of  Pa. 
Spender  (John  Kent,  m.d.),  Bath,  England. 


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